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STATE OF CALIFORPIN WATER RESOURCES CONTROL BOARD FORM 'A': Vp^ a UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z COMPLETE THIS FORM FOR EAC10 H FACILITY/SITE `,�,.o.�,• MARK ONLY ❑ T NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 ERMANEN CL ED/SITE 1—a ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE —4 N 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) O FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Bic T4ew ADDRESS NEAREST CROSS STREET ✓ 0Y 0 PARTNUISIIP 0 SIATEAGENCY ( CNIPOMIION 0 LOGL-AGDCY 0 FIIEPAIAGENLY 0 NDADUA 0 ccM mENLY CITY NAME STATE ZIP ODE SI E PHONE It,WITH AREA CODE L CA 53 /5 5561-111415 TYPE OF BUSINESS: 2 DI IB OR 1 PROCESSOR ✓Box it INDIAN EPA ID N RESERT GASSTATION E] 3 FARM r OTHER TRUST ANDSTION ❑ ,A r} s NOITANS TRUST LANDS ✓� ��"' AT THIS SITE b EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE AYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) \ PHONE N WITH AREA COD NIGHTS: NAME(LAST,FIRST) P!HONE WITH AREA CODE IL PROPERTY OWNER INFORMATION & DRES — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & A DRESS — (MUST COMPLETED) NAME CA OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATIO AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. Ii. 111. E 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 N JURISDICTION N AGENCY N FACILITY IDN.`� 1 3� If S of TANKS et SITE -I- 3 0 CURREy.'['O LOCAL FDACI�IDN APPROVED BY NAME W11 PHONEN WITH AREA CODE i PERMIT NUMBER //V PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-0ISTRICT CODE BUSINESS PLAN FILED DATE FILED I 3 023• YES Ej NO CHECK PER YITA YOUNT SURCHAFIGEAMO NT FEE CODE RECEIPTN 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) DATA PROCESSING COPY Y-y