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STATE OF CALIFORNI WATER RESOURCES CONTROL BOARD o" ` FORM 'A': UNDERGROUND STORAGE TANK PROGRAM e SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 741— COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I 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 V is O I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS© I I NEAREST CROSS STREET ✓Boa taiMeate ❑ PARTNERSHIP ❑ STATE AGENCY �ZDC ElCDRPORANON El LOCAL ❑ FEDERAL AGENCY S, v/ ❑ INDIVIDUAL ❑ couNNAGENcY CITY NAME STATE ZIP CODE Sly PHONEp,`W`IT�H AREA CODE CA � ( – Z TYPE OF BUSINESS: 2 DISTRIBUTOR 4PROCESSOR ii/Box if INDIAN EPA ID p ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUSRESET LANDS ATION or 1:1X of TANK'F I AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(I-AST,FIRST) PHONE AWITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION __THDii MAILING or STREERESS ✓Box to indicate El PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 11LOCAL-AGENCY [IFEDERAL-AGENCY ,(�, TADD ❑ INDIVIDUAL [ICOUNTY-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 toindicate ❑ 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. ❑ 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 N LI --�� M of TANKS at SITE m LLD-J) / SALRRENT-rOCAL AGENCY FACILITY ID N APPROVED BY PHONE N WITH AREA CODE SCc)sv �- BER VAL DATE PERMIT E%PIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DIS ICT CODE BUSINESS PLAN FILED DATE FILED YES NO CHECKN 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. FOI.M A(3-2-BB) u 1 . �'3 S� `� DATA PROCESSING COPY