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t: STATE OF CALIFORNIA • WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM u " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z C COMPLETE THIS FORM FOR EACH FACILITY/SITE +p,.o ttt 1 MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWAL CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE C4 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) O FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS20 _ ,�m ` NEAREST CROSS STREET ✓Bpx biMceb ❑ PARTNERSHIP ❑ STATE AGENCY CITU NA V r v ❑ I101 Go iON ❑ COONTMGDO ❑ FEDERAL-AGENCY AGENCY STATE ZIP CODE SITE PHONE A,WITH AREA CODE CA TYPE DF BUSINESS: ❑2 DISTRIBUTOR ❑4'PROCESSOR H INDIAN EPA ID a ❑ 1 GASSTATION ❑3 FARM ❑5 OTHER RESERVATION or ❑ If of TANK'# TRUSTLANDSAT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE At WITH AREA CODE DAYS: NAME LASE,FIRST) PHONE N WITH AgEA CODE NIGHTS: NAME(LAST,FIRS--r) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) AME /\�� _ b�Ir✓ rM1S CARE OF ADDRESS INFORMATION 1 MAILING or STREET AURESS ✓Box to intlicate ❑ P ERSHIP� 13 STATE-AGENCY 100 I W, � ❑ CORPORATION CAL-AGENCY ❑ FEDERAL-AGENCY CRY NAME ❑ INDIVIDUAL LJ COUNTY-AGENCY t-1STATE ZIP CODE P ONE a,WITH AREA CODE F� `153310 2 -85�Sa III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ CORPORATION ❑ LOCAL-AGENCY � STATE-AGENCY 13 INDIVIDUAL ❑ COUNTY-AGENCYFEDERAL-AGENCY CITU NAME STATE ZIPCODE PHONE A,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. ❑ 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 It AGENCY R FACILITY ID a a of TANKS at SITE CURRENT LOCAL AGENCY FACILITY IO If APPROVED BY NAME PHONE#WITH AREA CODE T—z o PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F D YES NO CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 4 D 0 BY: THIS FORM BUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-110) DATA PROCESSING COPY