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STATE OF CALIFORNIP WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE l FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE r� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 05 CHANGE OF INFORMATION ❑ 7 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) Y CLOSED SITE Imi a) Od FACILITY/SITE.bCARE f"5 •"iVriir ••. hF OF DRESS IN ,,OR ATION V x to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY Ill CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ADDRESS /I /V ` NEA ROSS STREET✓�110 ST �w—_ indicate ❑PARTNERSHIP ❑ STATE -AGENCY A CARPORATION ElLOCAL-AGENCY❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME � t �0 STATE CA _ SITE PH NE # � H AREA CODE 5 �� / i Z 2 1 f z 4 PROCESSORF-/ ❑ 5 OTHER 10 EP�;IA F C4®OR\P EMERGENCY CONTACT PERSON (PRIMARY) Y CLOSED SITE Imi a) Od FACILITY/SITE.bCARE CARE OF AD RESS INFORMATION ik OF DRESS IN ,,OR ATION V x to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY Ill CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ADDRESS /I /V ` NEA ROSS STREET✓�110 ST �w—_ indicate ❑PARTNERSHIP ❑ STATE -AGENCY A CARPORATION ElLOCAL-AGENCY❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME � t PHONE , WITH AREA CODE STATE CA ZIP CODE SITE PH NE # � H AREA CODE 5 �� / i Z 2 1 f TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR �/ I -J GAS STATION ❑ 3 FARM 4 PROCESSORF-/ ❑ 5 OTHER Box if INDIAN ST LANDS or ❑ EP�;IA F # of TANK's /y AT THIS SITE (rf� EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS::NAME (LAST,FIRST) � J PHO�NE #1 WITH AREA CODE ) ( DAYS: NAME (LAST, FIRST) PHOVE # WITH AREA CODE NIGHTS: NAME (LAST, FIRSTf fl, PHONE # WITH AREA CODE g�' 2.- �-Z q b NIGHTS: NAME (LAST, FIRST) S PHO E # WITH AREA CODE S/A II. PROF4RTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) Nq � �✓. CARE OF AD RESS INFORMATION ik MAILING or STREET ADDRESS . (�" 2, r/ �`/_ � ,� � V x to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY Ill CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY j j / I/W��. � ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE , WITH AREA CODE III. TANK OWNEMINFORMATION & ADDRESS — (MUST BE COMPLETED) NAME � �/ CARE OF ADDRESS INFORMATION MAILING or S EET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY # of TANKS at SITE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY I I I j ❑ 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: 1.0 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 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. FORMA (3-2-88) 0 DATA PROCESSING COPY 4. 1 JURISDICTION # AGENCY# FACILITY ID # # of TANKS at SITE W I I I j E[ ® � d p a AGENCY�.FAACCILITY ID # APPJPjR�O�VED BY N PHONE # WITH AREA CODE J %/ / .6 F PER T PP VAL DATE PERMIT EXPIRATION DATE CENSUS TRACT # SUPERVISOR (STRICT CODE BUSINESS PLAN FILED DATE FILED �,/ YES NO ll /PERMIT AMOUNT SURCHARGE AM UNT FEE CODE RECEIPT # 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. FORMA (3-2-88) 0 DATA PROCESSING COPY 4. 1