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STATE OF CALIFORA WATER RESOURCES CONTOL BOARD /5";..,:;.i a FORM `A': SIT UNDERGROUND STORAGE TANK PROGRAM rv' y FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �m COMPLETE THIS FORM FOR EACH FACILITY/SITE Y �,® e e MARK ONLY ❑ J NEW PERMIT ONE ITEM ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 2 NEW PERMIT N AMENDED PERMIT 7 PERMANENTLY SED SITE ¢.-> I. FACILITY/SITE INFORMATION &ADDRESS — O s COMPLETED)SITE CLOSURE 1. I (MUST BE COMPLETED) FACILITY/SITE NAME Gyre c k;h CAPE OF ADDRESS INFORMATION ADDRESS AA NEAREST CROSS STREET ✓Bulom. ❑ PARTNERSHIP 0 ATE AGENCY CITY NAME , ❑ COR PGNI N ❑ LOCAL AGENCY ❑ FEDERAL AGENCY ❑ IND MDUAL 13 COUNTY.AGENCY TYPE OF BUSINESS STATE ZIP CODE SITE PHONE p,WITH AREA CODE E]2 DISTRIBUTOR n CA q PR E R ✓Box if INDIAN EPA ID a 1 GAS STATION 3 FARM TTOHER RESERVATION or El +vv(� TRUST LANDS N of TANK'N EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE DAYS. NAME(LAST,FIRST) EMERGENCY CONTACT PERSON(SECONDARY) SPHONE p WITH AREA CODE DAYS NAME(LAST FIRST) '7— �/ � WITH ACODE PHONEp REA NIGHTS: NAME LAST,FI ) a I( PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CV CARE OF ADDRESS INFORMATION MAILING or STREET ADDgF$S J`• ✓Box to intlicale ❑ PARTNERSHIP RTNERSHIP 1 v ❑ CORPORATION ❑ LOCAL-AGENCY El STATE-AGENCY CITYNAME ❑ INDIVIDUAL ❑ COUNTY- Y 0 FEDERALAGENCY STATE AGENC ZIP DE �+ PHONE p.WITH AREA CODE / 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME #0 CARE OFADORESS INFORMATION MAILING or STREET ADDRESS �A ✓Bax m intlicale ❑ PARTNERSHIP ❑ CORPORATION EELOCAL-AGENCY STATE-AGENCY CITY NAME ❑ INDIVIDUAL ❑ COUNTY- � 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 LEGAL NOTIFICATION AND BILLING: I. 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) GATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# If of/TANKS at SITE CURRENT LOAGENCY F CILITY IDN O A APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION C DE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED CHECK M IL PERMIT AMOUNT YES F] NG /�l SURCHARGE AMOU T FEECODE OC RECEIPTN Y. 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(3-2-88) \\�V\/ 06 DATA PROCESSING COPY