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STATE OF CALIFORNi� WATER RESOURCES CONTR;�BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM Z SITE /�'' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PE N E r ONE ITEM [—] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6 416 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) A FACILRYYSI NAME CAREOF. DRESS INFORMATION ADDRESS _ N EST CROSS STREET ✓BPbIdGB 13 PARTNERSHIP ❑ STATE AGENCY ,( I ❑ COHPGRATION [I LOCAL AGENCY �S1E�R4�lyp;�NC�Y lD C/ (/6110 l/•'•A�� ❑ INDYIWk ❑ OJUNfY.RGENCY CITY NAME STATE ZIP DE SITE PHONE*.WITH AREA CODE L��i CA z.(/0 TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Boz if INDIAN EPA ID * If of TANK's ❑ ❑�/ RESERVATION or ,} ❑ 1 WSTATION ❑3 FAFN U✓ 5 OTHER TRUST LANDS ❑ ��/rD A7 THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) D S: NAME(LA .FIRST PHONE WIT AR CODE DAYS: NAME(LAST FIRST) PHO �Q NEp WITH AREA CODE Mij /A NIGHTS: NAME(IASTFIRST) PHONE N WITH AREA CODE NI H7 . NAME(LAST.FIRST) PHWITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BBJEdBCOMPLETED) NAMP CARE OF ADD ESS INFORMATION MAILINp or STflEET ADDRESS ✓/60.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY P ❑ CORPORATION ❑ LOCAL-AGENCY DERA -AG CV • ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STA ZIP CODE ONE*, ITH AREA CODE CA 1 47 z i 687 -vy/ 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMNGE _A CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boz 1.indicate ❑ PARTNERSHIP O STATE-AGENCY. -` ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ 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. ❑ 11. 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,I S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE SII LOCAL AGENCY USE ONLY COUNTY B JURISDICTION R AGENCY R FACILITY ID R R of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID• APPEIOVF,D BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE RM EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTfiICT CODE BUSINESS PLAN FILED DATE FILD -1 2_33 / YES [] NO CHECK PERMIT AN40UNT SURCHM0 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 ONLY. JFORM A(3-2-88) ,�, DATA PROCESSING COPY >• /