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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '` •°^ ^"^ FORM A : UNDERGROUND STORAGE TANK PROGRAM V SITE FACILITY/SITE, INFORMATION and/or PERMIT APP LICATIONp ` COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE ONE ITEM ❑p INTERIM PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Sp z I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 1 FACILITY/ASITE NAM' CARE OF ADDRESS INFORMATION V kI, ADDRES'S'7 //,,^^ NEAREST CROSS STREET ✓I3mbnacAk PUTTMgSHIP STAiE,IGFNLy rV ✓ C (�l/� l�C ❑ COFPgUToN ElLOCAAGENLY ❑ RDEBAI�WEACY Cl INNIOLUI ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE A.WITH AREA CODE 0 CA TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑1 PROCESSOR ✓Box it INDIAN EPA ID x ❑ I GAS STATION ❑3 FARM ❑5 OTHER 7pUMATIDS 0r ❑ Not TANK'a AT THIS SITE ON EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST.FIRSTI PHONE N WITH AREA CODE DAYS NAME(LAST FIRST PHONE A WITH AREA CODE NIGHTS NAME(LAST.FIRST) PHONE Al WITH AREA CODE NIGHT$ NAME(LAST FIRST) PHONE A WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OE ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box 1o,N,ca?. ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓EGA 10 io0icm. 0 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 WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: 1. II. ❑ ❑ III. ❑ TH/S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATUREI DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID M S of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE N WITH AREA CODE !�- r4Cirr7.214 Z3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D EFIL D YES ❑ NO CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: NN \ THIS FORM MUST BE ACCOMPANIED BY AT LEAST AMORE TANK PERMIT FORM 'B' APPLICATION(S), W 'THIS IS A CHANGE OF SITE INFORMATION ONLY.