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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD a, " FORM A: UNDERGROUND STORAGE TANK PROGRAM �0 SITE �ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I COMPLETE THIS FORM FOR EACH F ITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE TLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �� a'(J cr r I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAM/ES CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET S.to irdirale D PARTNERSHIP D STATE AGENCY ❑ CORPORATION Cl LOCALAGENCY D FEOEMbAGENCY U uJe r3 D INOWIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE CA JD y— L —36'S-3 TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p RESERVATION or #of TANKS ❑ 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 It WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION I/CO✓[ SC /- ,• Ge - MAILINGorSTREETADDRESS 1/80.tc,rdcate D PARTNERSHIP Cl STATE-AGENCY Cl CORPORATION Cl LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE �i� i III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to md,cate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY Cl FEOERAL-AGENCY Cl INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.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. ❑ II. ❑ If. ❑ 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# JURISDICTION# AGENCY# FACILITY ID k #of TANKS at SITE 3 j = = I d 1 c 1 a 3 s _c-1 C` e? o CURRENT/LOCAL AGENCY FACILITY IID# APPROVED BY NAME PHONE#WITH AREA CODE PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED VES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: cl-0 ,/y/ 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. , ^ 6- ORM A(3-2-88 \! v J \ �� ,� DATA PROCESSING COPY / n /