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STATE OF CALIFORN WATER RESOURCES CONTR6C40ARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE J FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE C,OF R�r MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION TLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) FACILITY/SITE Nn � �6�� CARE OF ADDRESS INFORMATION ADDRESS rf/{ NEARS T CROSS STREET ✓i3o><loindi m ❑ PARTNERSHIP ❑ STATE-AGENCY I `� J/A' ❑ L�ORPORAnoN ❑ LOCAL-AGENCY El R_[.IERAL-AcENC1' b v OJ '■ ❑ IeviDUAL ElCaNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID # N of TANICS ❑ 1 STATION ❑ 3 FARM E] STLANOS 5 OTHER RESERVATION or GAS AT THIS SITE 1,.J TRU ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAT,FIRST) PHONE#WITH AR ODE PAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ,. 17 - 6LO NIGHTS', NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODS II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE!f,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME - STATE ZIP CODE PHONE M,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, ❑ II. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. -rf APPLICANT'S NAME(PRINTED&SIGNATURE) DATE - LOCAL AGENCY USE ONLY FCUARENT JURISDICTION N AGENCY M FACILITY ID li k of TANKS at SITE o70 61 1AGENCY FACILITY ID 9 APPROVED BY NAME - PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ��'�3 *� YES NO gam/7-0 �/ CHECK K PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY:[I`� I�1• . J THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION40 LY. FORM A(3-2-88)