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STATE OF CALIFORNIP WATER RESOURCES CONTROBOARD FORM `A': a UNDERGROUND STORAGE TANK PROGRAM go SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 7 COMPLETE THIS FORM FOR EACH;! ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENT SED SITE ONE ITEM ❑ a ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAM � CARE OF ADDRESS INFORMATION ADDRESS AREST CROSS STREET ✓BotlovNirale ❑ PARTNERSHIP ❑ STATE AGENCY ✓) I A ❑ COAPoMTION ❑ LOCAL.AGENCI ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTKAGENCY CITY NAME STATE ZI ODE S E PHON p,WITH AREA CODE TYPE OF BUSINESS'. CA �(9 Cao BI"-24a/ ❑ 2 DISTRIBUTOR ❑ d ESSOR I/Box it INDIAN EPA ID a ❑ 1 GAS STATION ❑ 3 FARM FEX OTHER RESERVATION or ❑ - 0 of TANK'Y TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAV - N NMEJLAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(I-AST,FIRST) PHONE p WITH AREA CODE o / NIGHTS NAME(LAST, tS �, /) PHONE p WITH ARE CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME 6CARE OF ADDRESS INFORMATION JC MAILING or STRE&ADDRESS ✓Bax to intlicate ❑ PARTNERSHIP 13STATE-AGENCY ❑ CORPORATION O LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or$T ET ADDRESS ✓80x io ineicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADORBSS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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 CONTY R JURISDICTION R AGENCY R FACILITY ID M M of TANKS at SITE m = 1 -713111101616 / CURRENT LOCAL AGE CY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NU R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE C S TRACTS SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED a� (off a a YES NO CHECKY PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTa 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) •