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TATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD /s`x :, i, ORM 'A': p UNDERGROUND STORAGE TANK PROGRAM �" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o �. COMPLETE THIS FORM FOR EAC FACILITY/SITE `'��•oa��" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT El 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"+ ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) C" FACILITY/SITENAME ,/..�� CARE OF ADDRESS INFORMATION / (/� ADDRESS / NEAREST CROSS STREET ✓Bm rab b kb0 PARTNERSHIP 0 STATE.AGEWf ❑ cm unON 0 LGCALAGENCY ❑ RDERAL-AGENLY ❑ IxD JAI 0 COUNTY-AGENCY CITY NAME - STATE 21p��O SITE PHONE k,WITH AREA CODE CA TYPE OF BUSINESS: ❑p DISTRIBI ❑ 4 PROCESSOR _/Box N INDIAN EPA ID k RESERVATION or k of TANK's ❑ 1 GAS STATION ARM ❑ 5OTHER TRUSTLANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Q MAILING r BEET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ',o ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 1N IK, 0 INDIVIDUAL ❑ COUNTY-AGENCY CITU NAME i STAT ZIP CODE PHONE p,WITH AREA CODE 5� 9s�2oS 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicale 11 PARTNERSHIP 13STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY I ❑ INDIVIDUAL 0 COUNTY-AGENCY f CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. v II. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION N AGENCY A, FACILITY ID k If of TANKS at SITE 4/ / 151 101010 171 CURRENT LOCAL AGENC F 1k APPROVED BY NAME PHONEk WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [CHE Lf CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED D E ILED/� �L 23,2 2S"_ YES NO /.S �`7 L'TI PERMIT AMOUNT SURCHARGE AM CUNT FEE CODE RECEIPT k BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY,! FORM A(3-2-88) DATA PROCESSING COPY