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STATE OF CALIFORNI10 WATER RESOURCES BOARD FORM `A': �a gym UNDERGROUND STORAGE TANK OGRAM no SITE /1 FACILITY/SITE, INFORMATION and/or �P�I�i� APPLICATION l/ COMPLETE THIS FORM FOR EACH ILITY/SITE 'FOR" MARK ONLY T NEW PERMIT ❑ 3 RENEWAL PERMIT E�f5 CHANGE OF INFORMATION 7 PERMANENTLY SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SIT�EpNAME CARE OF ADDRESS JJN/FOORMATIT,19/N MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ ORPORATION 1:1 LOCAL -AGENCY ❑ FEDERAL -AGENCY ADDRESS� �— NEAREST CROSS STREET , ✓ Box ty irxlicale ❑ PARTNERSHIP ❑ STATE -AGENCY CORP✓aRATIQN- ❑, LOCAL -AGENCY ❑ FEDERAL -AGENCY CITY NAM +' r�1i' r INDNIDUAi ' ` ❑ COUNTY -AGENCY CITY NAME STATE Z�v�� SITE PHONE #, WITH AREA CODE L, ' 1 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN if EPA ID # # of 1 GAS STATION 3 FARM 5 OTHER ❑ ❑ ATION or ❑ TRUST PERMIT EXPIRATION DATE AT THIS SITE HIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) ' PHONE # WITH AREA CODE NIGHTS: NAME (LAS��PHONE j��E,A CODE NIGHTS:/NAME LASl �© PHONE AREA CODFw 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME f CAREJOF ADDRESS INFORMATION �/�/�/� ".TC!" i MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ ORPORATION 1:1 LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ PARTNERSHIP ❑ STATE -AGENCY 1:1 FEDERAL -AGENCY NDIVIDUAL ❑ COUNTY -AGENCY CITY NAM +' STATE ZIP ClODDEE�� PHONE #, WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME/nrj�� ,1 !j4, r,� CARE O�F/ DDRESS INFORMATION �f(O MAILING or STREET ADDRESS ,Q ✓ Box to indicate ION 13CORPORATION ❑ PARTNERSHIP ❑ STATE -AGENCY 1:1 FEDERAL -AGENCY 3 11 COUNTY AGENCY CITY NA STAT ZIP �� P _ #, WITH AREA E IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ It. ❑ 111. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. LOCAL All APPLICANTS NAME (PRINTED & SSIGNATURE)DAATTE 3ENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE 3 L0L0l/l/_l'5ddL)IOTO-_51 CUR�REyNT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE #WITH AREA CODE L, ' 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT # SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED DATE FILED a ?j � �3 YES NO � CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # BY: THIS FORM MUST BE ACCOMPANIED BY AT LEASTOQR MORE TANK PERMIT FORM `B' APPLICATION(S), UN S THIS IS A CHANGE OF SITE INFORMATIO NLY. FORMA (3-2-88) DATA PROCESSING COPY ,