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STATE OF CALIFORNIA* WATER RESOURCES CONTROL•BOARD gEll. ...AFF 4' 1 FORM `A': UNDERGROUND STORAGE TANK PROGRAM " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-11 NEW PERMIT F__13 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION 7 PE Er LOSER SITE Fi ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) CD CT1 FACILI /SITE NAME W✓r^�'� CARE ADDRESS INFORMATION to. ADDRESS / / c xx ,I NEA EST CROSS STREET ✓B.CORP01tlATIO VIARINLOCAL GEN Cl FSTATE EDERAGENEY ❑ CONDUALON ❑ LOG4LAGEEN ❑ fEOEAAbAGENEY ❑ INONIOdAL ❑ GOONIRAGENC/ CITY NAME STATE ZIP OD SITE PH NE a.WITH AREA CODE Qr CA 7i2 -7(.?_ (.?_7 Zfb TYPE OF BUSINESS. ❑ p TRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a /x� 1 GAS STATION 3 FARM 5OTHEfl RESERVATION or �" AT THIS SITE C.JD E] E] TRUST LANDS ElA /r EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(IAS$FIRST) .PHONEb0 WITH AREACODE NAME(LAST,FIRST) PHpp �ITH AREA CODE NIGHTS: NAME(IAST, IRST) PHONE a WITH AREA CODE NI HT NAME(LAST,FIRST) PH B WITH AREA CODE a SA � � II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREIfT ADDRESS ✓Box to Indicate ❑ PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME 51A CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE 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. z it. ❑ Ill. ❑ 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 p JURISDICTION R AGENCY R FACILITY ID P it o1 TANKS at SITE Ml E= IQ lo Ii CURRENT LOCAL AGENCY FACILITY ID If APPROV D BY M PHONE#WITH AREA CODE ,�. "� // � PERMIT NUMBER PERMIT APPROVAL DATE PERMIt EXPIRATION DATE LOCAT ON CODE CENSUS ACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ATE FILED / '11 -42- VES NO (( CNE M PERMIT AMOUNT 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 - SITE INFORMATION ONLY. FORMA(3-2-68) DATA PROCESSING COPY