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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD `T FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F__11 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAM/E CARE OF ADDRESS INFORMATION L. le ADDRESS ' NEAREST CROSS STREET ✓Bw Io ilMrale ❑ PAg1NEAGHIP ❑ STATE AGENCY coN Q 3�3 ❑ CORPORATION 13 LOCAL AGENCV Ill FEDERAL c El INDIVIDUAL 11COUIMAGENCY N CITY NAME STATE ZIP CODE SITE PHONE If,WITH AREA CODE W CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOfl ✓Box if INDIAN EPA ID a ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTY ATION LANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE a.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. ❑ it. ❑ 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 COUTY# JURISDICTION Al AGENCY# FACILITY ID# If of TANKS at SITE 1N71 /I E= loloololcd / CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE#WITH AREA CODE pOLc% � PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [CHECK OCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE - BUSINESS PUN FILED DATE FILED YES ❑ NO ❑ # PERMIT AMOUNT SURCHARGE AMOUNT 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. FORM A(3-2-58) %W DATA PROCESSING COPY �/