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o-� STATE OF CALIFORNI� WATER RESOURCES CONTROkOARD a- :E FORM A: UNDERGROUND STORAGE TANK PROGRAM (%" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE `="---"-'P MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMA ENTLCLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z IG I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME , / � ^� !3t„nV..� �fack CARE OF ADDRESS INFORMATION ADDRESS V ate' ` J� ,+V'` NEA EST CROSS STREET ✓BVtwoimk ❑ PAHiNE�IIP ❑ STAIEAGENCY {{•� /J �/� ❑ WRPGPATION ❑ LOCAL AGENCY ❑ EO nA n ENCY f 1 tl i C,� ❑ NiI ❑ WUIMAGRCf I_& CITY NAME J STATE ZIP CODE 9s-.2-01 SITE PHONE N,WITH AREA CODE ,v CA -: TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR RESERVATIOIAN EPA ID a Hof TANWa �1 GAS STATION ❑ 3 FARM ❑ 5OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) I DAYS: _RMNAME(LAST IRST) PHONE✓WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST PHONE k WITH AREA CODE I NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE j 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME i CARE OF gDDRESS INFORMATION W I' a- MAILINGorSTREETADD E ✓bon U64.m. ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ F DERA -AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STAT„ A ZIP CODE PHONE#,WITH AREA CODE p III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME e CARE OF ADDRESS INFORMATIO MAILING or ST AOQRE ✓B 1 intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY IY,✓/ ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FED L-AGENCY J ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATEZIP CODE PHONE M,WITH Al CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. 10 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY f/ JURISDICTION N AGENCY N FACILITY ID k If of TANKS M SITE CURRENT LOCAL ADIENCY FACILITYIO k APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER`r/,rl// PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 23, YES NO-a D CHECKK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* 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(3-2-88) `i' DATA PROCESSING COPY M✓