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STATE OF CALIFORNbK WATER RESOURCES CONTROTBOARDox i ' f Y A Y FORMA': UNDERGROUND STORAGE TANK PROGRAM i SITE, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM NeINTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Q I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION NEAREST CROSS STREET one 11 PARIllSWIP ❑ FEDOWAGENCY STATEAGEKY AbO ` mG ❑A7/ l PFAN Cl ILAL gyAGBICY CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE ,Fvw Ca Ao? 445-5675 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR Box if INDIANTION EPA ID N S of TANK'N ❑ 1 GAS STATION ❑3 FARM PI OTHER TRUST LANDS ❑ 1 AT THIS SITE 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE S ' n /� a09 VI6 - NIGH S: NA ST,FIRS ) PH(%E N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION 4 A Q MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 150 1123Z aS MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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. N 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE C 7 � � 1 0 -3 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE D KaSe F)le PERMITNUM R L r.` PERMR APPROVAL DATE PERMIT EXPI ON AIX P 3 � LOCA�TIIO CODE CENSUSTRACTN SUPER RANiTNICT CODE BUSINESS FI DATE FL�EID CY Lj 3, Fn qa YES ❑ NO ❑ l� AYD O ' CHECK N PERMIT AMOUNT SURLNAROE AMOUNT FEE CODE RECEIPT N 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-BBI VVV DATA PROCESSING COPY .--�