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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 9tf� l�f FORM 'A': UNDERGROUND STORAGE TANK PROGRAM o SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY LJ'1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE x ONE ITEM ❑ p INTERIM PERMIT E] 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q 0 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SI E NAME CARE OF ADDRESS INFORMATION T�`w `V ADDR NEWT CROSS STREET ✓Bptb ❑ PARTNERSHIP ❑ STATE-AG949 O ❑ TION ❑ LOXAGDO ❑ FEOEM-AGENLY C� NOMOGAL ❑ COUNlY AGENCY CITY NAME ` ' STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA Q TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID # ❑ KS I GAS STATION ❑ 3 FARM OTHER TRUST LANDS VATION or ❑ AT THIS SITE / AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Ra i i� NIGHTS: NAME(LAST. IRST)A -,,� n ONE#WITH AREA CODE NIGHTS' NAME(LAST,FIRST) PHONE#WITH AREA CODE 5 � - II. PROPERTY OWNER INFORMATION 8 ADDRESS — (MUST BE COMPLETED) NAME t CARE OF ADDRESS INFORMATION MAILINGO STREET ADDRESS -/Box toind,i ❑ PARTNERSHIP ❑ STATE-AGENCY M11 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY S ❑ INDIVIDUAL ❑ COUNTY-AGENCY CIN NAME STATE ZIPCODE I PHONE#.WITH AREA CODE O a k, U,41 C/4 lCyt5 ag'S 77iV 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAMES �� CARE OF ADDRESS INFORMATION/ J MAILING or STR ADDRE//��SSu ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. 11. 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#� JURISDICTION# AGENCY# FACIL NB7 TANKS BI SITE = s op CURRENTL NCYFACILITYID# APPR VED BYNAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERM EXPIRATION DATE LOCATION CODE CENSUS TRACT�p SUPE RVISOR-DISS�CODE BUSINESS PLAN❑FILED NO ❑ DATE toCIA/1 3 . YES CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: A/` THIS FORM MUST BE ACCOMPANIED BY AT LEAST 01 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATIO7 FORMA(3-2-8&) '" DATA PROCESSING COPY �"'}