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STATE OF CALIFORNS WATER RESOURCES CONTROL BOARD �m FORM A: UNDERGROUND STORAGE TANK PROGRAM z ; �� - . o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ;� 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENT] CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) A FACILITY/SITE NAME ,[ jCARE ADDRESS INFORMATIO 6rLuue. l✓L rfvl till ADDRESS �O ES CROSS STREET ✓Bow lq inticaIO ❑ PARTNELOCALAStPGEN ❑ FEDERSTME AGENGY /VA) f(�J-C. 'LAyOA•it1 ❑ INDII lIAl10N 13 O COUNTYY AGENCYCY ❑ FEDEIIALAGENQ'CITU NAME TE ZIP CODE SITE PHO p.WITH AREA CODE CA qr b 2d - ^4 'z-?-' TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # #of TANKS E] 1 GAS STATION ❑ 3 FARM OTHER TRUSTY ATION LANDS o ❑ �✓ A AT THIS SITE 06 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS' AME(LAST,FIRST) PH ITH AREA CODE NIGHTS: NAME(LAST, ST) PHONE#WITH AREA CODE NIGHT$ NAME(LAST,FIRST) P N WITH AREA CODE S /, S ) IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF DDRESS INFORMATION MAILING rSTREET ADDRESS //l/✓/ 3m to intlicate ❑ PARTNERSHIP Cl STATE-AGENCY /) ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY [J I � INDIVIDUAL ❑ COUNTY-AGENCY CIN NAME 1W✓—v STATE ZIP CODS PHONE p WITH AREA CODE ,L� U 1 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME ACARE OF ADDRESS INFORMATION MAILING o,STIREET ADDRESS ✓Rox to micate ❑ PARTNERSHIP ❑STATE AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It.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. 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# JURISDICTION If AGENCY# FACILITY ID If #of TANKS at SITE [Aeq 1 ( 1 -7 FOTOJEE CURRENT LOCAL AGENCY FACILITY ID# APVROV U BY NAME PHONE#WITH AREA CODE PERMIT NUMBER =PERMIT DATE PERMIT E%PIA ON ATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ATE FI EDA 7 n YES NO `'2 CH K PERMIT MOUNT 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 ONLY. FORM A(3-2-88) a DATA PROCESSING COPY