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STATE OF CA41FORNO WATER RESOURCES CONTROL BOARD FORM `A': We. � UNDERGROUND STORAGE TANK PROGRAM '` i~ ,m SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION `; COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 DERMA ENT CLOSED SITE I' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) IL1TY/ TE NA E A I CARE OF ADDRESS INFORMATION DRE NEAREST CROSS STREET ✓Box Io Wale ❑ PARTNERSHIP ❑ STATE AGENCY t ❑ C6RPDRATIDN ❑ LOX AGENCY ❑ IEDEHAL-AG£NCY CITY NAME ❑ INDIODl1AL ❑ COUNTY-AGIACY STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA ai S"3 j TYPE OF BUSINESS: 2 DISTRIBUTOR ❑4 PROCESSOR Bo if INDIAN EPA ID N ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTYLANDS or ❑ N of TANK's AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME{LAST.FIRST) PHONE It WITH AREA CODE DAYS NAME{LAST,HRST} PHONEY W17H AREA CODE 1 NIGHTS fff NAME(LAS7ClF[IASIT) V PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST ) PHONE p WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME T 7 CARE OF ADDRESS INFORMATION MAILING Or STREET ADDRESS- ✓BOX to indicale ❑ PARTNERSHIP r17 ❑ CORPORATION ❑ LOCAL-AGENCY '❑ FEDER L-AGEN CITY NAME © INDIVIDUAL ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — ( UST BE COMPLETED) NAME CARE OF ADDRESS INFOHMATION GL�J MAILING or STREET ADDRESS ✓gax to indicale EJ PARTNERSHIP Ll STAT&AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY CITY NAME ❑_INDIVIDUAL E❑ COUNTY-AGENCY STATE ZIP CODE PHONE N,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, III. El THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. APPUCANT•S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS of SITE � �� r �� K Ecoo r CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME �/ 7 PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DIST ICT CODE BUSINESS PLAN FILED 7 DATE FILED q n y o �Jl� YES © NO � % �� (J CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# By, THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERM IT FOR M 'B'APPLICATION(S), UNL 6QAM A(3-2-N8) 5 THIS IS A CHANGE OF SITE INFORMATION ONLY. � DATA PROCESSING COPY r �