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STATE OF CALIFORNI. - WATER RESOURCES CONTROL-BOARD a FORM 'A': UNDERGROUND STORAGE TANK PROGRAMSITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �3 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME J CARE OF ADDRESS INFORMATION 0 Y C kA U Pers PM ADDRESS NEARESTCROSSS REET ✓Rmk Mick Cl PARTNEI&IIP D STATE AGENLY ❑ cowo AMIN D LGCALmDcr D RGEPAL-AGEIILY / D limrwk D G AGBlcr CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE S CA TYPE OF BUSINESS. ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID N M of TANK'k ❑ 1 GAS STATION 3 FARM � RESERVATION or ❑ AT THIS SITE❑ 5 OTHER TRUST LANDS 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 ]EE 209 -3 0& NIGHTS: N ME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION p e MAILINGor STREET ADORE ✓Box loi dicate PARTNERSHIP ❑ STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE GcIcl ; C ?5ay0 III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION patine as MAILING or STREET ADDRESS ✓Box M indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D 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. ❑ it. 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 S JURISDICTION R AGENCY k FACILITY ID R S of TANKS N SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN❑FILED NO ❑ 2 3, 'n Ls- CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT0 BY: 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 INFORMATION ONLY; (FOII�I A(3-2-&&) I /��