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. . . e. :l t.. '-T9"r..'9.".'� .fir {`-'TTaT`Sim"�T—T'�r^�-^—„•T^^".Tt+'T"vwse^n _. STATE OF CALIFORNO WATER RESOURCES CONTROL BOARD "i^” "E FORM `A': m UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o COMPLETE THIS FORM FOR EACH ACILITY/SITE "A'•a^='" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT lef 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDSITE F'a ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE GO -4 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 00 FACILITY75ITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Box At Ntale ❑ PARTNERSHIP ❑ STATE AGENCY Al./ ❑,GBAPORATION ❑ LOGAL-AGENCY ❑ FEDEPALAGENCY _ /Y. /J D 13 INDNIDIIAt ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE CA �3(pfo - 5 9 9 - 383 TYPE OF BUSINESS: ❑2 R[BUTOR F—] 4 PROCESSOR ✓Box it INDIAN EPA ID p ❑ ESE 1 GASSTATION 3 FARM ❑ 5 OTHER TRUSTVATION LANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE ft WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE ft.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE ft.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. lv� II. ❑ 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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION If AGENCY N FACILITY ID At M of TANKS at SITE = = o -7 / CURRENT LOCAL AGENCY FACILITY 10 M_ APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATELCODE PERMIT EXPIRATION DATE LOCATI N CODE CENSUS TRACT a SUPERVISOR-DISTRBUSINESS PLAN FILED DATE FILED � �3.�3 3aYES ❑ NOCHECK k PERMIT AMOUNT SURCHARGE AMOUODE RECEIPT a BY: L] 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(3-2-81]1) DATA PROCESSING COPY