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STATE OF CALIFORNIP WATER RESOURCES CONTR04ROARD W FORM 'A': UNDERGROUND STORAGE TANK PROGRAMl �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓B IirndCNO 0 PAATNERS4IP 0 STATE AGENCY 9300 0 CO80RATIDN 0 LOX AGENCY 0 FEDEMLAGENCY ❑ INDMDOAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE SjTE POHONE a.WITH AREA C D�O CA l/o'c 4 5 TYPE OF BUSINESS: ❑p DI IBUTOR ❑ 4 PROCESSOR */Box if INDIAN EPA ID p E] 1 GASSTATION 3 FARM E] 5 OTHER TRUSTYLANDS Or ❑ N ✓ - — "' AT THIS SITE I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS AME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE Ca in 599-i o NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME p CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to moll 11 PARTNERSHIP 0 STATEAGENCY L/D A ❑ CORPORATION 0 LOCAL-AGENCY 1:1FEDERAL-AGENCY TT 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME i STATE ZIP CODE PHONE N,WITH AREA CODE I III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION a ^^ `` MAILING or STREET ADDRESS V Box to intlicao 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS11116 O :1y CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 11nI. ❑ 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 R JURISDICTION S AGENCY R FACILITY ID S A o1 TANKS AI SITE = gef CURRENT L/OC,ALL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE T� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LGC ON CODE CENSUS TRAY'C�T N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D 7 FILED O� YES ❑ NO ❑ c///5 ? CNE KN I PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM SY: 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 ONLY FORMA(3-2-}18)O a •