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STATE OF (CA L I FO R N Ik WATER RESOURCES CONTROL. BOARD w+i E FORM 'A': "' UNDERGROUND STORAGE TANK PROGRAM ��TE COACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ka ' COMPLETE THIS FORM FOR EACH CILITY/SITE C,�FOR,", MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P NTLY.CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE i tJ I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME �AJ-TA--4S71179 CARE OF A RESS INFORMATION LL ~I D ADDRESS NEAREST CROSSSTREET ✓B"10w ax ❑ PARTNE&P ❑ STATE-AGENCY �,,// /� �j�/ ❑ CORPORATION ❑ LOCAL-AGENCY ❑ MI)ERAL-AGENCY D f/I / /C/ (/ �' -� ❑ INDMWAL ❑ COLtM AGBICY CITY NAME � STATE ZI�0DE� SITE PHONE ITH REA 00 CA TYPE OF BUSINESS: F-1 2 DISTRI8UTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N RESERVATION or •of TANK's ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE 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 II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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 MAILING or STREET ADDRESS ✓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 CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR DOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ IIL❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION 0 AGENCY k FACILITY ID A 0 of TANKS at SITE I Lbl-0-I / &41 slfl I o 1r) IaE�f CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAIVE PHONE A WrrH AREA CODE J PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION C DE CENSUS TRACTN SUPERVISOR-OISTRI CODE BUSINESS PLAN FILED DATE FILED �f YES ❑ NO [:] 17_L CHECK N PERUrr AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N DY: ,I/ (N ZFOA FORTH OUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERw FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORVIAT10N ONLY. (3-2-88) _ c