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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM = ' o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION a< , o LlCOMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE N ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) N (TI FACILITY/SITE NAME fir)^ _ CARE OF ADDRESS INFORMATION A4C ClEe ADDRESS NEAREST CROSS STREET ❑ MMISIF ❑ STATE-AGFNCY 3 S 011O ❑ RXPL-AcwLY ❑ INomwu �-M CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE t 1X) CA �20 Z :/ -ssl TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROC R ✓Box R INDIAN EPA ID p ❑ I GAS STATION E]3 FARM THER TRUSTVATION LAND$ur ❑ / W ,� AT THUS SITE I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE f NIGHTS: NAME(LAST.FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) j NAME CARE OF ADDRESS INFORMATION . PG 1 e: I MAILING or STREET ADDRESS cate El PARTNERSHIP 11 STATE-AGENCY ATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY yS- - 1I ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE ,TH AREA CODE j C R s l III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION PG e �— MAILING orSTREETADDRESS -/Box to indicate 11PARTNERSHIP El STATE-AGENCY F? O �V 11 INDIVIDUA11 L 13 13COUNTY--ENGY AGENCY ClFEDERAL-AGENC CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE CA- pis I IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION N AGENCY# FACILITY ID If It of TANKS at SITE I Cao I / ) Ict I si I I I Il CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE p WITH AREA CODE RCI F PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACpTT-#-7� SUPERVISOR-DISTRICT,CODE BUSINESSPUNFILED DATE F11I.EO 3 •U L./ I YES E] NO ❑ 1 ?. CHECKIV PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 0 BY. ` THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON W1 FCRM A 13-2-88) DATA PROCESSING COPY I.,r