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Ox's STATE OF CALIFORNIA" WATER RESOURCES CONTROL BOARD A t FORM A: UNDERGROUND STORAGE TANK PROGRAM =" S T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �} COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PER D SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/ 2d V. V 1ay-i �(�', //q CARE OF ADDRESS INFORMATION ADDRESS � NEAREST CROSS STREET ✓BmbYHrale ❑ PUTTIMM1P 13 STATE AGENCY ❑ CgPM70N ❑ LOCAL�ACOO 0 FEIEIULAGENCY 0 INOMWAL 0 O NIYAGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA COOE�a Lp C�c CA v 3 O�rSS1P TYPE OF BUSINESSSTRIBUTOR 1PROCESSOR ✓Box if INDIAN EPA IDn Not TANKY ❑ RESE I GAS STATION E] 3 FARM ❑ 5 OTHER TRUSTYLANDS or ❑ 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 Y 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 ✓Bortoindicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 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 N/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CDY 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 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 R JURISDICTION N AGENCY R FACILITY_IDN----- R of TANKS of SITE CUIRI LOCAL AGENCY FACIL APPROVED BY NAME PHONE N WITH AREA CODE ') 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ECHECK# CODE LPERMITAMOUNT TN BUPERVI8077 STRICT CODE BUEINEBBPSNFILED NG ❑ 1 LIED SURCHARGE AMOUNT FEE CODE RECEIPT N THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-8 8 )