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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD i FORM `A': UNDERGROUND STORAGE TANK PROGRAM m; SITE A- FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m to COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7.P TLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION K s� ni ,✓ ADDRESS �y NEAREST CROSS STREET ✓ k El PNRNE1 IP ❑ SIAffaGENCi i v / 0 CA9PC VON ❑ LOCM AGDO ❑ FEDWL AGBILY �. _HENM{FN/✓ .eV 0 INDMOUAL Cl ODUM-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA 9sz 5� TYPE OF BUSINESS: ❑2,WRIBUTOR ❑4 PROCESSOR I ✓Box if INDIAN EPA ID p RESERVATION or Fol TANK ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE 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 KlP- 9,N BAA,,, 1) ten, v NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME S/ CARE OF ADDRESS INFORMATION �Q GES MAILING or STREET ADDRESS ✓Box toindicete 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY 0 INDIVIDUAL Cl 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 MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 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. I. ❑ 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 R JURISDICTION# AGENCY B FACILITY ID R N o1 TANKS M SITE CURRENT LOCAL AGENCY FA LITY IDJ APPROVED BY NAME PHONE If WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-OISTRICT CODE BUSINESS P$YES NO ❑ DATE FILED0 qll I� CHECKP PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: U THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM'B'APPLICATION($),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) DATA PROCESSING COPY �✓✓/)))