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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 41 d+ COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENrTLY ED SITE ONE ITEM ❑2 INTERIM PERMIT ❑N AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE X I. FACILITY/SITE INFORMATION 8 ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bm b�bY.911 ❑ PARMERSIP 0 STATEAGENLY ❑ CORPORATION C1 LGCAFAaNLY ❑ FEDERALAGDKY ❑ 00110 AL ❑ GGHrr-ACHIa CITY NAME STATE ZIP CODE SI FE PHONE V.WITH AREA CODE CA TYPE OF BUSINESS: 2 DISTRIBUTOR ❑N PROCESSOR I ✓BON d INDIAN EPA IDN Y 01 TANK'. ❑ 1 GAS STATION ❑ 3 FAFM ❑S OTTER TRUST TION ur ❑ 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 NIGHTSNAME(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 ✓Bo.to ind"I" ❑ 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) fJAML CARE OF ADORLSS INFORMATION MAILING of 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 ABOVB ADDBBBS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 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 N JURISDICTION B AGENCY N FACILITY ID N N of TANKS.1 SITE = = I I 1;� 13 171-511 1 1 1i CURRENT LOCAL AGM61 FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE i PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO CHECK If PERMIT AMOUNT lURCHMOE AMOUNT FEE CODE RECEIPT BY: t_ 4 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'L' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. �-� FORM A(3 2 NB1 — ✓ W