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vi STATE OF CALIFORNIA' WATER RESOURCES CONTROL BOARD `. FORM `A': UNDERGROUND STORAGE TANK PROGRAM ,ter SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m.l. COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE —�P ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Z 10 I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) FACILITY/SITE NAM CARE OF ADDRESS INFORMATION N N � ADDRESS J,J'� NEAREST CROSS STREET ✓EmmiMie8le PARiN ASHIP D STATE-AGENCY CORPORATION L-AGENOV D FEDERAL AGENCY fj7 ❑ INDIVIDUAL ❑ C0UN7r-AGENCY CITY NAME STATE ZIP CODE ITE PHO N,WITH AREAC��gp�E CA jrS3 76 ' 7`�S� TYPE OF BUSINESS: ISTRIBUTOR ❑ 4 PROCESSOR -/Box if INDIAN EPA ID N M of TANKN RESERVATION❑ ❑ ❑ TRUSTILANDSo ❑ 1 GPS STATION 3FAPM 5OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME S$FIRST) I�4 PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE I d 8 jGY> NIGHTS. NAME(LAST,FIRST HONE N WITH AREA CODE NIGHTS: NAMEKAST,FIRST PHONE N WITH AREA CODE j II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 66 MAILING or STREET ADD IPSVBox to indicate 13 P&SXWEIISHIP ❑ STATE-AGENCY JLL� D CORPORATIONCAL-AGAGENCY D FEDERAL-AGENCY (/ ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME ^— STATE ZIP CODE PHONE p.WITH AREA CODE LIZ. s3 111. TANK OWNER INFOR ATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION it MAILING or STREET ADD S ✓Box to indicate DERSHIP ❑ STATE-AGENCY �1D CORPORATION AL-AGENCY D FEDERAL-AGENCY (J D INDIVIDUAL COUNTY-AGENCY CITY NAME STATEZIP CODE PHONE N,WITH AREA CODE l C� 9 3 7� IV. LEGAL NOTiFICATIOPfAND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. �I APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY i COUNTY M JURISDICTION N AGENCY N FACILITY IDM M o1 TANKS at SITE m CURRENT LOCAL A,QWY FACILITY ID N APPROVED BY NAME_ PHONE N WITH AREA CEDE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT IRATION DATE J PFORMA C E CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 �— YES NO _ PERMIT AMOUNT SURCHARGE AMO T FEE CODE RECEIPTIf BY: M MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 88) \\ `�' DATA PROCESSING COPY J