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STATE OF CALIFORA WATER RESOURCES CONTRO BOARD ;s -� j e FORM 'A': g��,. : �_, UNDERGROUND STORAGE TANK PROGRAM ; " o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o COMPLETE THIS FORM FOR EACH ACILITY/SITE `'r�Fow�`" MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY L SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �U' co 1 co I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE W�ME CARE OF ADDRESS INFORMATION i i ADDRESS �y NEAREST CROSS STREET 1:1 FAWNERSE D STATE AAATON 11 LOCALAGNCY ❑ FEDDIALAGENL YS S INDIVIDUAL ❑ COUNtt AGENCY CITU NAME STATE ZIP CODE SITE PHONE 11,WITH AREA CODE S CA a TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # RESE❑ r It of TANK's I GAS STATION ❑ 3 FARM THE TRUST LANDSATION ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE 54,II K Ci((Q NIGHT5: NAME(LAST,FIRST) PHON WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Wi ! a nk MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY 1 I ❑ CORPORATION D LOCALAGENCYD FEDERALAGENCY OO ( L M ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME ,y, /' /�CA Ci/'r STATE /� ZIP CODE PHONE#,WITH AREA CODE 1 U 5 ( III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME _56"e��'� CARE OF ADDRESS INFORMATION 4l/YY�e MAILING or STREET ADDRESS ✓Box to Indicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY D 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. ❑ it. 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE 12131710L . 1 I CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATAIONCODE CENSUSTRA`C/T# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED -I 2 'b� 11 YES � NO 2 '� CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT At 1 1 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. � FORMA(3-2-88) • DATA PROCESSING COPY 0