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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD a FORM 'A': UNDERGROUND STORAGE TANK PROGRAM S�� , FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m : G ( COMPLETE THIS FORM FOR EACH FA LITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE FD 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS N AREST CRM�OSS STH�EEyyE,,T/� / ✓9wwF 0 PABRIEISHP 0 STATE AGRILY A Rh-llY�k-LC. /C Q. ❑ MVMTM ClLocu�AC 13EEODw MINCY CITY NAME /' STATE ZI CODE SITE PHONE It,WITH AREA CODE 156 CA o;)O r/ —Jr TYPE OF BUSIN SS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box if INDIAN EPA ID If F Of TANK'F ❑ ESE 1 GAS STATION ❑3 FARM OTHER TRUSTVLANDS or ❑ AT THIS SITE 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE a 3 NIGHTS. AME(LAST,�RST^I a PHON a WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING w STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY El INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING.STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE V.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. ❑ Ill. ❑ 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 R AGENCYIN FACILITY ID I1 N of TANKS at SITE Eff] = BOG s7 003 CURRENT LOn AGENCY FACILITY ID F APPROVED BY NAME PHONE F WITH AREA CODE R PERMIT NU BER PERMIT APPROVAL DATEL�i PERMIT EXPIRATION DATE LOCATION ODE CEN�TSUS TRAC(TT O SUPERVISOR-DISTRICTBUSINESS PLAN FILED DATE FILED d3 � 6 �, p�-� YES ❑ NO ❑ /0//3 CHECK F PERMIT AMOUNT SURCHARGE AMOUNTODE RECEIPT F BY: Li THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATWN(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY< �RM A 13-2-88) J