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STATE OF CALIFORNI9 WATER RESOURCES CONTR OARD a FORM IA': _ v 'm UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �lliro xa\P COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 9?117 PERMANENTLY CLOSED SITE ONE ITEM El2 INTERIM PERMIT El4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Ielo_4Ac c,. ADDRESS NEAREST CROSS STREET ✓ in XX,e 0 PARTNERSHIP 0 STATE AGENCY 3 1 n coreoanTax ❑ tocALA ❑ EEOEra�acExw /'y A ❑ ixomouA ❑ COUNT AGENCY CITU NAME STATE ZI ODE SITE PHONE p,WITH AREA CODE CA 3 TYPE OF BUSINESS'. ❑ DISTRIBUTOR ❑4 PROCESSOR ✓BOX if INDIAN EPA ID N F 01 TANK's RESERVATION or ❑ AT THIS SITE F__] 1 GAS STATION ARM ❑ 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY Cl INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S S i MAILING or STREET ADDRESS ✓BOX to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOT(INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. If. ❑ 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 k JURISDICTION Al AGENCY M FACILITY ID k M of TANKS at SITE " 0 3 6100101 CURRENT AL AGENCY FA ILITY I0 APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER ('N�/ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAT N CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED '�• 'l "'l YES NO CHECK• PERMIT AMOUNT SURCHARGE AMOUNT PEE CODE RECEIPT s BY: 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. ` N FORM A(3-2-BS)