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STATE OF CALIFORNfA Oa` f FORM 'A': WATER RESOURCES CONTROL BOARD rsE raf SITE UNDERGROUND STORAGE TANK PROGRAM FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION: ^ ?4;➢ �o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT "r,Fogr�" dE ONE ITEM ❑ ❑3 RENEWAL PERMIT �5 CHANGE OF INFORMATION 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 7 PERMANENTLY CLOSED SITE I. FACILITY/SITE INFORMATION &ADDRESS — ❑s rEMPoggqvslTEaosuRE r\ s� C FACILITY/SITE NAME (MUST BE COMPLETED) ' CARE OF ADDRESS INFORMATION ADDRESS _ NEAREST CROSS STREET r Q S/ PARTNERSHIP'0 0 LOCAL G IV 0 AGENCY GEN CITY NAME ❑ COAPoAATION ❑ LOGALAGENGY ❑ FEDERAL AGENCY STATEZIP CODE INDIVIDUAL 0 COUNTY- AGENCY SITE PHONE#,WITH AREA CODE TYPE OF BUSINESS: E]p DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID #A ❑ 7 GAS STATION ❑3 FARM 5 OTHER RESERVATION or EMERGENCY CONTACT PERSON(PRIMARY) TRUST LANDS ❑ #of TH AS T THISITE DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON(SECONDARY) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓BOX to iod,c.le ❑ PARTNERSHIP CITU NAME 0 CORPORATION C LOCAL-AGENCY 0 STATE-AGENCY ❑ INDIVIDUAL CCOUNTY-AGENCY 0 FEDERAL-AGENCY STATE ZIP CODE PHONE a,WITH AREA CODE ' III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boxto innate ❑ PARTNERSHIP CORPORATION 0 LOCAL-AGENCY 0 FEDERSTATEAL-AGENCY L-AGEN AGENCY CITY NAME ❑ INDIVIDUAL ❑ COUNTY- C FEDERAL-AGENCY STATE AGENCY ZIP CODE PHONE p,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH H IEGAI NOTIFICATION AND BILLING 1 ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AN CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #o/TANKS at SITE CURRENT / 1 LOCAL AGENCY FACILITY 10# Z_ / o Ws APPROVED BY NAME r PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT k 6 SUPERVISOR-DISTRICT CODE 23 XZ 1 BUSINESS ALAN FILED CIL/ GATE FILED CHECK# PERMIT AMOUNTYES ❑ NO � U Q n SURCHAR EAMOUNT FEE CODE i RECEIPT# BY. AA V` THIS FORM MUST BE ACCOMPANIED BY AT LEAST R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. N�FORMA(3-2-SS) k_) \J � I / v DATA PROCESSING COPY b N �