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STA(TE OF CALIFORNI A� WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE L'Faa MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE O ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT El TEMPORARY SITE CLOSURE �/ I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W CD FACILITY/SITE NAME CARE OF ADDRESS INFORMATION F e-44" /'Cin A ADDRESS NEAREST CROSS STREET ✓Boz 10,t ale ❑ PARTNERSHIP ❑ STATE AGENCY ❑ TI ClLOCALAGENCY El FEDERAL ) 6;10 INDnIDUIL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE 164 0^. CA 9S3/i 6 at79'S"99' Yso TYPE OF BUSINESS D 2 Dq§TRIBUTOR ❑ 4 PROCESSOR ✓Be,if INDIAN EPA ID a RESERVATION or X of TANK's ❑ 1 GAS STATION 3 FAflM ❑ 5 OTHER TRUST LANDS ❑ 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 ur6c NIGHTS' NAME(LASE FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION AG°u/ 6OF MAILING or STREET ADDRESS ✓Box 1 indicate ❑ PARTNERSHIP ❑ STATE-AGENCY / ❑ 'ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Q/ �j/ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 5 3 (0 (0 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION C!/xe Q5 MAILING or STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. ❑ it. 111. ❑ 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# AGENCY# FACILITY ID# #of TANKS at SITE NT-L6C GENCY FACILITY ID X APPROVED BY NAME PHONE#WITH AREA CODE PERMIT N APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES j NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:_ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL q FORM A(3-2-RB) \ V DATA PROCESSING COPY