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STATE OF CALIFORNIor WATER RESOURCES CONTROrBOARD FORM IA': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PNTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT E]4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE /_EgMANE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLFTFm FACILITY/SITE NAME /n /7S G'a CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION ADDRESS I/ Be. to indicate 0 PARTNERSHIP ❑ STATE -AGENCY NEAREST CROSS STREET ✓&a*eoW 0 PABTNERBIP 0 SIAHEKRLY __�_ I / 1 7 3 M ❑ INDIVIDUAL 0 COUNTY -AGENCY 0 0 IYIIWMHTM ❑ UD AC¢NLY 0 FRXPAAGENLY ZIP CODE PHONE N, WITH AREA CODE C� OPN�P «F MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PNTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT E]4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE /_EgMANE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLFTFm FACILITY/SITE NAME /n /7S G'a CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION ADDRESS I/ Be. to indicate 0 PARTNERSHIP ❑ STATE -AGENCY NEAREST CROSS STREET ✓&a*eoW 0 PABTNERBIP 0 SIAHEKRLY __�_ I / 1 7 3 M ❑ INDIVIDUAL 0 COUNTY -AGENCY CITY NAME 0 IYIIWMHTM ❑ UD AC¢NLY 0 FRXPAAGENLY ZIP CODE PHONE N, WITH AREA CODE PHONE Y WITH AREA CODE PERMIT NUMBER ❑ INDIVIDWL 0 CWIC( GENCY CITY NAME STATE ZIP CODE SITE PHONE p, WITH AREA CODE CENSUSTRACTS / CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 1 ESSOR ✓iI INDIAN BO%US7VLANOS EPA ID N / CHECK ❑ I GAS STATION 3 FARM or ❑ 5 OTHER Tg FEE CODE X of TANK'F AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE N WITH AREA CODE DAYS. NAME (LAST, FIRST) PHONE N WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE N WITH AREA CODE NIGHTS: NAME ()AST, FIflST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION A AnnRFcc — tui Icy mc Imams, crc... III. TANK OWNER INFORMATION A AnnRFcc — That ICT lac /rn Alol crcm% JURISDICTION# NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/ Be. to indicate 0 PARTNERSHIP ❑ STATE -AGENCY = ❑ CORPORATION 0 LOCAL -AGENCY ❑ FEDERAL -AGENCY __�_ I / 1 7 3 M ❑ INDIVIDUAL 0 COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE N. WITH AREA CODE III. TANK OWNER INFORMATION A AnnRFcc — That ICT lac /rn Alol crcm% IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ Ill. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY JURISDICTION# NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box lo,ad,cale 0 PARTNERSHIP 0 ;TATE = AGENCY 0 CORPORATION 0 LOCAL -AGENCY 0 FEDERAL AGENCY __�_ I / 1 7 3 M 0 INDIVIDUAL 0 COUNTY -AGENCY CITY NAME 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: 1. ❑ II. ❑ Ill. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY THIS FORM MUST BE ACCOMPANIED BY AT LEAST (I) OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A (3-2-83) lftae DATA PROCESSING COPY TE iR JURISDICTION# AGENCYAF FACILITY ID R K of TANKS at SITE rnUNTY# �J--�J = = __�_ I / 1 7 3 M CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE Y WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACTS SUPERVISORSDISTRICT ODE BUSINESS PUN FILED DATE FILED 71 Z7 YES ❑KECEIPTENO❑ / CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE THIS FORM MUST BE ACCOMPANIED BY AT LEAST (I) OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A (3-2-83) lftae DATA PROCESSING COPY TE iR