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t p STATE OF CALIFORNAI WATER RESOURCES CONTROL BOARDS FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION rs COMPLETE THIS FORM FOR EACH FACILITY/SITE °'i,roap`P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION 7 PEPAMUEbaLY CLOSED SITE N ONE ITEM 1:12 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �D I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) A FACILITY/SI N!.E CAREOF OD RESSINFORMATION ADDRESS (,�-•LIQ II CROSTfl ✓Aev iMicele 13PANTNERSHIP ❑ STATE AGENCY ❑ RPOMCllTION LOCAL AGENC( FEDERALAGENCY INDNIDUAL ❑ COUNTY-AGENCY CITY NAME STATE SITE PH NE WITH AREA CODE.n L- _U *ate CA -) TYPE 0 USINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N 1GASSTATION ❑3FARM ❑ 5OTHER TRUST LANDS oI ❑ Z6 7/ AT THIS SITE 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAY : NA VEST,FIRST) PHONE It WITH AREA CODE DAYS' AME(LAST,FIRST) PHO WITH AREA CODE b'7- 06) NIGHTS: ME()AST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHON WITH AREA CODE 4 S la `]( II. PROPERTY OWNER INFORMATION &ADDRESS —(MUST BE COMPLETED) NA �, I CAREOF AOGRESS INFORMATION 10 MAILING or `E`PyAD ET ADORES" y ✓//Boo.to intlicatePARTNERSHIP ElSTATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME � STAT ZIP CODE PHO eIATH AREA cont' III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) T� NAME, CARE OF ADDRESS INFORMATION MAILING at STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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: 1. ❑ 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 N JURISDICTION N AGENCY a FACILITY ID N P of TANKS at SITE H 10101 1 p CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY III I N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL P R ITE (RATION DATE LOCATI N CODE CENSUS TRACT MQ/l SU ISOR-DIS ICT CODE BUSIN $S PLAN FILED DATE FILIBID YES N l CHEck It I PERMIT AMOUNT SURCHARGE AMOUNT FEE E RECEIPTN y: THIS FORM MUST BE ACCOMPANIED BY AT LEAST It1 OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) -' DATA PROCESSING COPY