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STATE OF CALIFORPA WATER RESOURCES COAL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Vo Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE q g N 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) -4 A FACILITY/SITE NAME CARE OF ADDRESS INFORMATION e CJI ADDRESS NEAREST CROSS STREET ✓BBryryhh`V- 0 PARTNERSHIP 0 STATE AGENCY L3 RPORATION Cl LOCAL AGENCY 0 FEDERAL AGENCY -t 0 INDIVIDUAL 0 COUNTY AGENCY CITY NAME [STATE ZIPCODE SITE PHONE q,WITH AREA CODE q 5717 -- 3 TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓BOA if INDIAN EPA ID a tAT of TANWs tAl GAS STATION [:]3 FARM ❑ 5 OTHER TRUSTYLANDS o F-1 THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) ME CARE OF ADDRESS INFORMATION II MAILING.,STREET ADDRESS 3A{3 MYR�L� �� )SVLr�+ Nt✓t Boxmintlicate 0 PARTNERSHIP 0 STATE-AGENCY ''IIII''IIS^L .1T60RPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY "ITV 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE c�- q- - Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) N E CARE OF ADDRESS INFORMATION I ` MAILING.r STREET ADDRESS y✓e.x m intlicaie 0 PARTNERSHIP STATEAGENCY M 2 _ k.RjopORATION 0 LOCAL-AGENCY Cl FEDERALAGENCY .J5u= dLAO ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME ST ZIP CODE ENE N,WITH AREA CODE v , 33 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 1& Ill. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE D CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID If R of TANKS at SITE CURRENT LOCAL AGENCY FACILITY IDM I APP50VED BY NAMEHONE M WITH AREA CODE 60 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO \ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM 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 0 LY. DATA PROCESSING COPY 0