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STATE OF CALIFORNIA WATER RESO ES TROL BOARD ,r FORM `A': UNDERGROUND STORAGE TANK PROGRAM Z u m) SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m COMPLETE THIS FORM FOR EACH FACILITY/SITE �"'��^"'H MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT GnlS`CHANGE OF INFORMATION ❑ 7 PERI CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00N I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS �� f` NEAREST CROSS STREET ✓BaVigimk 11PIJTW04P 11STATEAGEICY R�37i / J/ju(J ❑ caPaunlx+ 13iauAeFMY ClFWXrA+c CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE CA J��b TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ SSOR ✓Box it INDIAN EPA ID x A of TANK'Y ❑ 1 GAS STATION ❑3 FARM 5 OTHER RESERVATION or TRUST LANDS ❑ AT THIS SITE / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE P WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE H. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME &P D iAARE OF ADDRESS INFORMATION ft N �✓ Dge MAILING or STREET ADgoXDRESS-� O Box to mocato ❑ PA ERSHIP ❑ STATE-AGENCY OCCORPORATICAL-AGENCY ❑ FEDERAL-AGENCY 11 INDIVIDUAL COUNTY-AGENCY CITY NAME QSTATE ZIP CODE PHONE III WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to inoicale ❑ PARTNERSHIP 0.XfAYi ❑ CORPORATION ❑ LOCAL-AGENCY FE ERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PH E 11,W H AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS I 00i CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. H. 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 p JURISDICTION S AGENCY B FACILITY ID N E of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE A WITH AREA CODE 6okAAdl PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRI T CODE BUSINESS PUN FILED DATE FILED YES NO � / CHECK N PERMIT AMOUNT SURCHARGE AMO NT FEE CODE RECEIPT K 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. FORM A(3-2418) DATA PROCESSING COPY v `.