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STATE OF CALIFORA WATER RESOURCES CONT• BOARD 9e FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FA ITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 17 ONE ITEM ❑ Z INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Jr'/ I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION �' - Z �oa� ADDRESS NEAREST CROSS STREET ✓ft 0 PARTNER&F 0 STATE-AGENCY TION 0 LOCALAGENCY 0 FEDOIALAGENCY Gt`� et led �u o ❑ NDmDUu ❑ Caxn.AGaa CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE � r�c/c fcw� CA 95720-5- TYPE 0 USINESS. ❑ 3 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # X of TANK1 1 GAS STATION ❑ 3 FARM ❑ S OTHER TRLISTYLANDSATION ot ❑ AT THIS SITE C� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS I/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME - CARE OF ADDRESS INFORMATION z- — 9 /its: MAILING o,STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE AGENCY / /� ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY Y��✓ Lafl ( lle A 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE Xl/ e;s:c Ca IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ II. ❑ 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 N JURISDICTION X AGENCY X FACILITY ID X X of TANKS N SITE O C7 CURRENT LOCAL AGENCY FACILITY 10 X APPROVED BY NAME PHONE X WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED C) / 3b0 3 a3 YES ❑ NO � S�9p CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: c 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. 1 FORM A(3-2-BB) a 2,) Q,