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STATE OF CALIFORA WATER RESOURCES CONTI BOARD sE FORM 'A': UNDERGROUND STORAGE TANK PROGRAM7- Pill SITEv FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o COMPLETE THIS FORM FOR EACH FACILITY/SITE ,� 1 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED S1TE r ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C C I. FACILITY/SITE INFORMATION & ADDRESS (MUST BE COMPLETED) FACILITY/SITE NAME J 5_7CARE OF ADDRESS INFORMATION A-IJl ✓QlZ,A. ADDRESS � ///,/ NEAREST CROSS STREET ✓Box to iWULY El PARTNERSHIP 13 STATE�� ❑ NBR CORPORATION 0 LOCAL El CO NMAGfCY 13 FEDERAL CITY NAME STATE ZIP�DE SITE PHONE N,WITH AREA CODE CA 24 TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID x ❑ I GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS or ❑ #of TANK'HIS SITE AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY❑ 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 STREET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,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.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED fl SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# IF DI TANKS at SITE 2y � CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE A/ 6'it/ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT UPIRATION DATE 1-1 LOCA`R5L"LN CODE B T A TO SUPENyISOfl- 1 TRICT CODE BUSINES,PSN HIILEO NO ❑ DATE FILE CHECK# PER TANGENT SURCHHAARGE AMOUNT FEE CODE RECEIPT Y f'/BY- THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONS NLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A r%-88) N DATA PROCESSING COPY