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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '' x'` FORM 'A': UNDERGROUND STORAGE TANK PROGRAM c �o S!T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE °aa"�" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME _ CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓ ibcBk ❑ PARTNERSHIP ❑ STATE AGENCY PO( ❑ LOCAL.AGENOY ❑ ms&AGENGY ❑ INOMOWL L] WOI(IY AGENCY CITY NAMESTATE ZIP CODE SITE PHONE a.WITH AREA CODE S CA TYPE O BUSINESS. 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box ii INDIAN EPA ID a ^r GAS STATION 3 FARM 1 5 OTHER RESERVATION or nI D�YLQ. AT THIS SITE V ❑ ❑ TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST.FIRST) PHONE Al WITH AREA CODE DAYSNAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE Al WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME1 D CARE OF ADDRESS INFORMATION 'T�/ A MAILING o REET AD ESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY I /_ [' El CORPORATION ❑ LOCALAGENCY13 FEDERAL-AGENCY I(/J ❑ INDIVIDUAL ❑ COUNTY-AGENCY CIN NAME S: p � STATE ZIP P /E�WITIf-21 110D V wC/G C Y 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 'S- ct"2, B(uy1 GLJ MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY 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. ❑ II. ❑ 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 R JURISDICTION M AGENCY R FACILITY ID R S of TANKS BI SITE .3916 1 d DDos CURRENT LOAL AGENCY FACILITY ID It APPROVED BY NAME PHONE N WITH AREA CODE e PERMIT NUMBER j PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L E CEN]MB TRACT SUPERVISOR']-0ISTRICT CODE BUSINEM PLAN FILED DATE FILEOj v ` YESPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• BYJ N THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORM LY. VV l i FORM A(3-2-88) J