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R,...-.s�.,,.,,.�,�..�-.r+r'r..-..r.......-..�—...—��-n.-.�..R.••----•�,..o--,;+->.,_�..--• A'i' t4'•r.•--r+q�.^r^ly.n.r .-.�..sar --e,['[,....r�..,y.. _ I STATE OF CALIFORNY WATER RESOURCES CONTROL BOARD PSE OF r FORM `A': UNDERGROUND STORAGE TANK PROGRAM Alm SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - ; 10 COMPLETE THIS FORM FOR EACHCILITY/SITE -IF 'p, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Eql5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CIO I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CD Vi FACILITY/SI AME CARE OF ADDRESS INFORMATION 5c ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Ci 2-11101111 PID ElLOCAL-AGENCY ElFEDERAL-AGENCY1, �(/-b/,_/ I INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE TYPE OF BUSINESS: n 9 f VRIBUTOR F__] 4 PROCESSOR ✓Box if INDIAN EPA ID N FL---JIy' RESERVATION or #of TANK's ❑ 1 GASSTATION 3 FARM ❑ 5 OTHER TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Sa rm MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OW ER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME ( CARE OF ADDRESS INFORMATION 1 MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. 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 [ERMITNUMBER JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE FM `� � 1 / 1 AGENCY FACILITY ID# APPROVED BY NAME PHONES WITH AREA CODE --[PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUSTRACT# SUPERVISOR-DISTRICT CO E, BUSINESS PLAN FILED DATE FILED YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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. FORMA(3-2-88) DATA PROCESSING COPY 0