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STATE OF CALIFORNIP WATER RESOURCES CONTROL 0ARD �� 4 yEP iu��wi'jM1f FORM IA': UNDERGROUND STORAGE TANK PROGRAM �o z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I COMPLETE THIS FORM FOR EACH FACILITY/SITE �'"F�e='" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE } 09 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) Clr) 00 FACILITY/SIT NA CARE OF ADDRESS I N FORMATI Ory IAI� i oY, Ti �� I,A�}L— ADDRESS NEAREST CROSS STREET ✓Bg�W iIbiCBle Cl PARTNERSHIP ❑ STATE AGENCY 2 r ..0'FIJflPoAATIDN Cl LOCALAGENCY ❑ FEDERAL AGENCY J ❑ INDIVIDUAL Cl COONIY-AGENCY CITY NAME STATE V J SITE PHONE#,WITH AREA CODE CA TYPE OF BUSINESS: F—] F—]2 DISTRIBUTOR 4 PROCESSOR -/Box if INDIAN EPA ID #RESER (vvii1�S �J f l a of TANK' GAS STATION 3 FARM ❑ 5 OTHER TRUSTY ❑ 1:1LANDS ATION or �— AT HIS SITE �J EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(( ST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE it WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓80x to n,do.te ❑ PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAI U NG or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl 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. 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# It of TANKS at SITE Ehl 10U Ii:=U OUOU CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE S_0 15 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# ODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED d� O v L -,-k L" YES ❑ NO ❑ e w l -( t PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ORM A(3-2-B8) DATA PROCESSING COPY