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. , ,�STATE OF CALIFORNIA" WATER RESOURCES CONTROL BOARD z" .o FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE IJ ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Q� I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE NgAIE co CARE OF ADDRESS INFORMATION JJ ADDRESS NEAREST CROSS STREET u to it JIM El 0 STATE AGENLY CORPOWON 0 LOX-AGEICY 0 FMMLAGENC aim I?qrl IrvomDU& 0 camT A cf CITY NAME f STATE ZIPCODE SITE PHONE N.WITH AREA CODE CA S� TYPE OF BUSINESS: p DISTRIBUTORIE�—�j(UI 4 PROCESSOR ✓Box if INDIAN EPA ID N E:] 1 GAS STATION ❑3 FARM l i l 5 OTHER TRUSTVLANDS ATION or ❑ AT TH S SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(f,LAST,FIRST) PHONE N WITH AREA CODE NIGHTS' NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODEPHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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: 1. ❑ 11. e 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 N JURISDICTION R AGENCY R FACILITY ID M R of TANKS N SITE 00r �? Iq10101012 CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE N WITH AREA CODE hme IRI;L 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ECHECK# CENSUS TRACT F SUPERVISOR-0ISTRICT CODE BUSINESS PLAN FILED DATE FILE 23,`dam YES NO ❑ 112,7 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT♦ BY: 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPUCATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) DATA PROCESSING COPY ��