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STATE OF CALIFORNIA- WATER RESOURCES CONTROCVbARD { FORM 'A': UNDERGROUND STORAGE TANK PROGRAM um SITE FACILITY/SITE, INFORMATION and/or ERMIT APPLICATION COMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLO SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACLTY/SITE AME CAR OF ADDRESS INFOR ATION 1 BJ EX 1 PS S 1(es ADDRESS fC� NEAREST G90S$STBEE[ BmbiCUV ❑ I'OM AG I( ❑ FEDEWGENLY 2 (A 1/(LA'lF NwoM x ❑ Loca 01111 ❑ STAM ENM` N Cl❑ IWNIDIN- ❑ WGIIIY-AGENCY CITYNAM STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA S33b -92S -2168 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 RES PROCESSOR ✓Dox if INDIANN EPA ID N F of TANK's [:] 1 GAS STATION [—] 3 FARM ❑ 5 OTHER ERVATIOor ❑ ATTHISSITE D3 TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 64s c Ps .ZO�c-82-3 -2168 a NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Gs MAILING or STREET ADDRESS ✓Box toindicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NA / CARE OF ADDRESS INFORMATION GS A MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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. ❑ 11. ❑ 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 R JURISDICTION B AGENCY M FACILITY ID S R of TANKS M SITE E 10 101 / g I vOd CURRENT LOCAL AOENC'YIFACILITY ID• APPROVED BY NAME PHONE N WITH AREA CODE N�ot PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CEN STRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 2 3t 32 YES ❑ No ❑ \ CHE F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT♦ B 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)