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STATE OF CALIFORNIx WATER RESOURCESCONTR&"BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - o COMPLETE THIS FORM FOR EACH F! CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"� ONE ITEM 1:12 INTERIM PERMIT ❑ #AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE � 1.FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) w ^�I FAGU ISITE NAME [� CARE OF ADDRESS INFORMATION ADORE:—,TNEAREST CROSS STREET O IPoxoore 13 ON ❑ ,OCA,-AGENCY ElSHOEIPLBAGENLY C / MOW, 11Cq.NT!-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE C CA Sx2'D TYPE OF BUSINESS: 2 DI IBUTOfl d PROCESSOR ✓Box N INDIAN EPA ID N ❑ 1 GASSTATION FARM ❑ 5OTHEfl RESERVATION or TRUST IANOS ❑ ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST FIRST) PHONE N WITH AREA CODE DAYS: NAME(IAST,FIRST) PHONE K WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NA CARE OF ADDRESS INFORMATION MAILWG ar STREET DRESS ✓goxt ,tale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STAT ZIPPOo11� PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETEDY)✓� NAME � ^ �` p CARE OF ADDRESS INFORMATION I, MAILING or STREET ADDRESS ACU t, ✓Box to indicate ❑ 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 f CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. RE ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED b SIGNATURE) DATE LOCAL AGENCY USE ONLY (}COOJ�UNTYY# JURISDICTION# AGENCY R FACILITY ID R M of TANKS at SITE L_'J CURRENT LOCAL AGENCY F ITY ID N APPROVED BY NAME PHONE If WITH AREA CODE Z mass, OG) li PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I LOCAMN CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI D YES [j No 1:1 � CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11)OR MORE TANK PERMIT FORM 'B'APPLICATIONIS), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88)r Snr/ DATA PROCESSING COPY y