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STATE OF CALIFORN11 WATER RESOURCES CONTROL BOARD GP FORM `A': UNDERGROUND STORAGE TANK PROGRAM go SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) m FA TV/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS G y�( N EST CROSS STP T ✓Row to lnairale D PARTNERSHIP ❑ STATEAGENCY ('' (p,� 0 CORPORATION D LOCAL AGENCY D FEDERk AGENCY [� ,,S) JLL'j GC/ { yZ/ L Cl INDIVIDUAL D COUNTY AGENCY CITY NAME I ) n STATE C53 ITE PHONE p,WITH AREA COD TYPE 0 BUSINESS: ❑(22DDIISTTRIIBBlUT`O,RR F-1(,1 4_PROCESSOR ✓Box if INDIAN EPA ID a OnY^J #of TANK'S RESER1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS TION or ❑ AT THIS SITE 10 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#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 & DDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE AGENCY ❑ CORPORATION D LOCALAGENCY0 FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - ( ST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box lo,odicate D PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL AGENCY D FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME TATE DECODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LE AL NOTIFICATION AND BILLING: I. ❑ it. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TN BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION k AGENCY# FACILITY ID# #of TANKS at SITE � l DL- O 16 O CURRENT L L AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PCHECK# ON CODE CENSUS TRACTJE SUPERVISOR-DISTRICT STRICT CODE BUSINESSPUN FILED NO ❑ DATE FILED PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1) ORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) DATA PROCESSING COPY 0