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n. _�,,•q.,....yrs,`,t-+„^-.m��.a'+�'Pif'�nlo+--.^-^�e':'rT,�"'sa"-�FrAfv�lRa�'�161�-F--..Y'�-=�. .. . . .. .:.,.,y�,,.,.,.: � .. . STATE OF CALIFORNY WATER RESOURCES CONTRBOARD FORM A : UNDERGROUND STORAGE TANK PROGRAM "a Z SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; to rgill COMPLETE THIS FORM FOR EACH FACILITY/SITE '.oa%" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANE LOSEO SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION t /( "Nit DDRESS NEAREST CROSS STREET x/&A to iitlioete ❑ PARTNERSHIP ❑ STATE AGENCY o LV /� .� p ❑ CORPOMTION ❑ LOCALAGENCY ❑ FEOERAbAGENCV I /", I IJ(� ❑ INDIVIDUAL ❑ CGUNTrAGENCY CITY NAME VW • _ STATE ZIP ODE SITE PHONE p.WITH AREA C=DE CA a 3 7 TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID s RESERVATION or R of TANK's ❑ I GAS STATION AflM ❑ S OTHER TRUST LANDS ❑ ATTHISSITE EMERGENCY CO TACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE hF- Rened ao &^-8 - 31 NIGHTS: NAME(LAST FIRST) PHONE k WITH AREA CODE NIGHTS. NAME(I-AST,FIRST) PHONE 4 WITH AREA CODE TJ- Aii e deifi, Fl rt K II. PROPERTY OWNER INFO MATION & ADDRESS — (MUST BE COMPLETED) NAME Je- CARE OF ADDRESS INFORMATION 5a4lll II MAILING or STREET ADDRESS ✓Box to lnolcate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE ft,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S C[S Sfe- MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 1,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE 11)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. it. ❑ 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 k JURISDICTION IF AGENCY B FACILITY ID If R of TANKS SI SITE ® I 1 1 Z412v 010o CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE 6 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-OISTRICT CODE BUSINESS PLAN FILED DAT FI ED YES [] NO a (� CHEC k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY; 1 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. `�1V1 FORM A(3-2-88) DATA PROCESSING COPY