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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V j SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �0 o COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I-� ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 4-3 a) I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ei &4v a Irl), ADDRESS NEAREST CROSS STREET 1/80AIr radiate ❑ POTNEASIIP ❑ STATE AGENO' Fd 0 COMORA70N [ILOCk AGENIX ❑ FEDEMLAGENCY K% ❑ INDMOUAL ❑ fAUNTY-AGENCY CITY NAMESTATE ZIP CODE SITE PHONE#,WITH AREA CODE a_k a� CA TYPE OF BUSINESS: ❑ ISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA 10 N X of TANK's ❑ 1 GAS STATION 3 FARM 6 OTHER RESERVATION or ❑ AT THIS SITE ❑ TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NCARE OF ADDRESS INFORMATION 0!5 MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE X,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NA CARE OF ADDRESS INFORMATION e GrS / MAILING or STREET ADDRESS ✓Box to,ndicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.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. vi 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# JURISDICTION IF AGENCY# FACILITY ID# #of TANKS at SITE � = = � � o CURRENT LOCALA C)VACILITY)" TAPPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER //�rllyy''//�1 ii'r�`ff// PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 1: YES NO E KN 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 OF SITE INFORMATION ONLY. FORMA(3-2-88) JC/ DATA PROCESSING COPY