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STATE OF CALIFORNIA 'W'ATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; (21 COMPLETE THIS FORM FOR EACH FACILITY/SITE cR -oRN P MARK ONLY Rif 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT G AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE ni p� I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION E-7- I F tj ADDRESS NEAREST CROSS STREET ✓ ox Io odicale ❑ PARTNERSHIP ❑ STATE-AGENCY - CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY - INONIpi © COUNTY-AGENCY CITY NAME ISTATE ZIP CODE TE PH NE p,WITH AREA CODE A2-07- EL TYr1i USINESS: Q 2 DISTRIBUTOR � 4 PROCESSOR ✓Box i1 INDIAN EPA ID # #of TANK's RESERVATION or AT THIS SITE STATION [_] 5 OTHER 3 FARM ❑ TRUST LANDS D EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME{LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 9 WITH AREA.CODE yl - r ,,�C NIGHTS: NAME(LA .FIRST) PHONE#WITH HHjAREA/CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE f C? II. PROPERTY OWNER IN ORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION —Z Se-Rv I MAILING or STREET ADDRESS „.✓.,, B o indicate El PARTNERSHIP El STATE-AGENCY I1CUFiPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY TOEl INDIVIDUAL Ll COUNTY-AGENCY CITY NAM STATE ZIP�G02EHIO)NE p,WITH AREA CODE r III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION z Sao?v 6- STATE NCY MAILING or STREET ADDRESS ,,..✓,.,,��•'�to indicate e ❑ PARTNERSHIP ❑ FEDERAL-AGENCY U�'CCIRPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY -3-550 F0I❑ INDIVIDUAL ❑ COUNTY-AGENCY GI NAME STAT Z[IIPPP C"O/DE ” ONE k WITH AREA CODE 703_ IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. ❑ 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 COLI JURISDICTION JURISDICTION# AGENCY# FACILITY ID# #of TANKS al SITE CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE k Ll 10 1_/ �7 lfi� 1610THE WITH AREA CODE C112--r PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAT N CODE CENSUS TRACT ACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FIL D f YES NO f __77 CHECK k PERMIT AMOUNT SURCHARGE Ami 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(3-2-1 0 {� DATA PROCESSING COPY ,J1