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STATE OF CALIFORNTA WATER RESOURCES CONTRZL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM =` o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , to COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE H-& ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6 I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION IPS o ca/ rlulcf ADDRESS NEAREST CROSS STREET ✓ IitiWl> ❑ PARTNE 11` ❑ STATE AGDO nM O CCOOUUa El Rmw A�cr CITY NAME STATE ZIP CODE SITE PHONE K,WITH AREA CODE CA sz or TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4PROCESSOR ✓Boz INDIAN EPA IDK If of TANKS ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER pgLISTT LANDS RVATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE K WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE K WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE K WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAA¢SS�� CARE OF ADDRESS INFORMATION e MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIPCODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box tcirWicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE K.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. ❑ 111.❑ 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 R JURISDICTIONS AGENCY S FACILITY ID N M of TANKS SI SITE fflz I I I �a a d CURREW LOCAL AGENCY�FACILITY IDA, APPROVED BY NAME PHONE K WITH AREA CODE /6ZIi' i PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LO ON CODE CENSUS TRACT KSUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Z3 2 S— YES F] NO LNECK K PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM 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. IN FORM A(3-2-53) Ib DATA PROCESSING COPY