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�j • ZEP o_F j4 STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ERMA OSED SITE ONE ITEM Oi ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE C7 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) C" FACILI /Ty SpE NAME _ CARE ADDRESS INFORMATION ADD R N✓BEST C�RO�S/♦S�TREE�T S.to 116.11 ❑ PARTNERSHIP ❑ STATE-AGENCY Z (�� ❑ASA ORATION ❑ !OCAL-AGENCY ❑ FEDERAL AGENCY 3i v�YWIW✓✓ +INDIVIDUAL ❑ COUNTY AGENCY CITY NAME� ' STATE ZIP SITE PH NE N.WITH AREA CODE ea, TYPE OF BUSINESS. ❑ 2 ISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID It #of TANK'# ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUSRESETATION LANDS or ❑ 41 AT THIS SITE 0 EMERGENCY CONTACT PERSON(PRIMARY) EMER ENCY CONTACT PERSON(SECONDARY) DA S: NAME(LAST,FIRST) PHONJ IT WITH AREA CODE DAYS: N LAST.FIRST) PHONE WITH AREA CODE lllrlk� o/4 NIGHTS: NAM T,FIRST) PHOZ 4WITH AREA CODE NIGHTS. NA (LAST.FIRST) PHO WITHAREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAMF/m _r, CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#,WITH gREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILIN6 or STREET ADDRESS 1/60.to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L II. ❑ 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 COUNTY# JURISDICTION At AGENCY# FACILITY ID At If of TANKS at SITE ® 1C) 101 .7 � d 10 1 CURRENT LOCAL AGENCY FAQI{!ITY IDM APPR VEp BY N IF�J PHONE M WITH AREA CODE S PERMIT NUMBER 80,J PERMIT APPROVAL DATE G/L/•/� PERMIT EXPIRATION DATE LOCAT CODE CENSUS TRACT#�f SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED FILED40NLY. YES NOCHEC # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODETHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE IN A(3-2-88) �� DATA PROCESSING COPY