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STATE OF CALIFORNIK WATER RESOURCES CONTROL BOARD /s` �:'"F FORM `A': UNDERGROUND STORAGE TANK PROGRAM u �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z C COMPLETE THIS FORM FOR EACH FACILITY/SITE `^��.a,��P to MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE _ I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME. CARE OF ADDRESS INFORMAT111 vS 'pl. z ADDRESS NEAREST CROSS STREET 'IB-bikrE ❑ PARTNERSHIP ❑ STATE-AGENCY S ❑ INGNYM11CWLA,GN ❑ RXMLAGC CITYNAME MDIIGFNC STATE 21P CODE SITE PHONE p,WITH AREA CODE CA 2oS� TYPE OF BUSINESS: 2 DISTRIBUTOR ❑4 PROCESSOR ✓Boz if INDIAN EPA ID # 1 GAS STATION ❑3 FARM ❑5 OTHER RESTRUSTYLANDS TIONor ❑ #of TANK's ATTR IS SITE I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to lntlicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE 21P CODE PHONE p,WITH AgEA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boxw m'cate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY EU�COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS N SITE i '--`�--'--1� CURRENT LOCAL AGENCY FACILITY ID Jr APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# DE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED \ .23. T0 Z YES NO 1 PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT If BY: ! 1 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. �\Jyl FORM A(3-2-88) r J \ � \ _as I f4/ DATA PROCESSING COPY Y.�