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STATE OF CALIFORNIA.- WATER RESOURCES CONTROL,--,.)ARD f w FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE ////��/ FACILITY/SITE, INFORMATION and/or PER.WT APPLICATION [/I COMPLETE THIS FORM FOR EACH FA ITY/SITE �"�" MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P LY CL D SITE ONE ITEM ❑Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Y 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS // JL/ NEAREST CROSS STREET ✓Bov bi4ule D RAMNY&P Cl STATE AGENCY 1! ` /� �/ 'v/5Al1AV ❑ CgPDSTION ❑ LOCAL AGENCY ❑ ROEML AGENCY ❑ INDMgW ❑ CWNIY.AGENCY CIN NAME STATE ZIP CODE SITE PMO M, T AREA COD�� CA TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID N _ N of TANK'aG7+ ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVLANDS o ❑ V AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NA E(UST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: IIAMP(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/o.to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY Cl INDIVIDUAL D COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bos to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY* JURISDICTION R AGENCY R FACILITY ID N N of TANKS Bt S1TE 39 3g CURRENT LOCAL AGENCYt C141T/JDi APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER //T)C// PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION COpE CENSUS TRACT N SUPE R-DIg8T111CT CODE BUSINESS PLAN FILED NO DATE�i� O !, CHECK♦ PERMIT AMOUNT BUR ARGF AMOU FEE CODE RECEIPT I 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. A�l� FORMA(3-2-88)