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ATE OF CALIFORNO WATER RESOURCES CONTR BOARD z; AtUNDERGROUND STORAGE TANK PROGRAM > ,ORM 'A': m SITE C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �q�,F®�' COMPLETE THIS FORM FOR EACH F LITY/SITE MARK ONLY (� 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION i PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT IJ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE (A I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) C?3 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET7el ✓ IPC)RATi Cl PARTNERSHIP Q FEDERAL-AGENCY � �5 A CgRPQRATION ❑ LUCAL--AGEN ❑ FEIIERAL-AGENCY I ❑ INDIVIDUAL ❑ GOUNTY-AGENCY _ STATE. ZIP CODE SITE PHONE#,WITH AREA CODE CITY NAME ("'0 TYPE :BUSINESS � 2 DISTRIB TOR Q 5©THER�R RESERVLAAT�bDNS or O it INDIANEPA ID # AL�z AT THIS SITE L t GAS STATION 3 FARMTRUST EMERGENCY CONTACT PERSON[PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) WITHH C DAYS: NAME(LAST,FIRST} PHONE#WVTH AREA CODE DAYS: NAME{LAST,FIRST) Q) (u�H _ '7 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATiON &ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME v f_ ✓ to ind[cale ❑ PARTNERSHIP Cl STATE-AGENCY MAILING or STREET ADDRESS 5 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 7 YY ❑ INOlVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE#,WITH AREA CODE CITY NAME w � ` �!5�i n fo III. TANK OWNER INFORMATION & ADDRESS — (MIS—ST BE COMPLETED) TION NAME GENCY MAILING or STREET�+{7DRESS �..1 ✓ tc Indicate ❑ PARTNERSHIP ❑ FEDERSTATEAL-AGENCY��rJJ (,�yvJ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY STATE ZIP CODE P E#, ITH AREA CODE CITY NAME 30 IV. LEGAL NOTIFICATION AND BILLING ADDRESS J�� CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. IL E III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE I jz] [�Hl I I I I I- I I I ro EHEjL3 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRI D E B SINESSP S N FF FILED NO ❑ DATE ` D YOl l CHECK k PERMIT AMOUNT SURCHARGE AM EE CODE RECEIPT# 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(3-2-68) 0 0 DATA PROCESSING COPY