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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE F LITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ ( NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PER 3 ITE /V ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Cn H1 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CJ FACILI P TE NAME J J CARE OF DRESS INFORMATION ApDRESS NEA EST CROSS EET ✓ IoiMicate 11 PARTNERSHIP 11 STATE-AGENCY . Q � COAPGRATIGN 11 LOCAL 11FEDEMiAGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP COpE SITE PHON #,WITH AREA CODE Go �� CA 7S ?_ TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 P CESSOR ✓Box i1 INDIAN EPA ID r ❑ 1 GASSTATION ❑ 3 FARM 5 OTHER TRUSRYLANOS ar ❑ 00/T AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) tQhV$ NAM (LAST FIRST) PHONE p WITH AREA C00 DAYS: NAME(LAST,FIRST '((J ) PHON p WITH AREA CODE VA A NIGHTSN ME(LAST,FI ) PHONE I WITH AREA CODE NIGHT NAME(LAST.FIRST) PH #WITH AREA CODE S14 a S 4 II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP Cl STATE AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE 1 III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CAREOFAD RESS INFORMATION MAILING rSTREET ADDRESS ✓ ox Loindicate ❑ PARTNERSHIP ❑ STATEAGENCY5 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ��/Ill ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITU N,AME u f I STATE ZIP CO TIT n PHONE p EA CODE )ALA IV. LEGAL NOTIFICATION AND BILLING ADDRESS CASS i��y CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 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# JURISDICTION M AGENCY# FACILITY IDM #of TANKS at SITE Jff] li� lo I / VTP_Ti�:t FoTo_Fo_Fp_1 CU NT LOCAL AGENCY FACILITY ID# APP OVED BY NAM PHONE M WITH AREA CODE 10) t,�l� 3� PERMITNUMBER PERMITAPPROVAL DATE PERMIT EXPIRA ION DATE LOC ION CODE CENSUUR � SUPERVISOR PICT CODE BUSINESS YPELS N FILED NO DAT ILEA CHECK N 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 1(3-j-88) HES DATA PROCESSING COPY