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STATE OF CALIFORNI WATER RESOURCES CONTROCBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM =" o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANEN, ED SITE I� ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �3 —4 cn 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CO c" FACILITY/ ITE NAME/ "e, CARE OF ADDRESS INFORMATION IIAJPX ADDRESS l/v C A /� NEAREST CROSS STREET But Mule ❑ PAWNEF&IP ❑ STATE-AGENCY I VO N/ I � ❑ INDIVIDUAL 13 13 LOCAL AGENCY 11 COUNTY AGENCYFEUEA AGEN CY CITY NAME 1. STATE Z P CODE SITE PHONE k,WITH AREA CODE CA saOs� TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a RESERVATION or R of TANK's ❑ 1 GAS STATION Ye3 FARM ❑ 5OTHER TRUST LANDS ❑ ATTHISSITE 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 k WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME / CARE OF ADDRESS INFORMATION ale MAILING or STREET ADDRESS ✓Box toirtdicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE# WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME / CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS B.to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE ft.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: 1471 if. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY R FACILITY ID N R of TANKS at SITE 0= lelolo CURRENT LL]GAIAA��FACILITY ID If APPROVED SY NAME PHONE If WITH AREA CODE PERMIT NUMBER G/!vl PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOC ON CODE CENSUS T�RTA-C�T N SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATTEE FIVO ;Z3A 2Z 25 — YES ❑ NO 1T 1 ICHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p BY: `p I 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. FORMA(3-2-88) DATA PROCESSING COPY