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STATE OF CALIFORNIA- WATER RESOURCES CONTR02ARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; co COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT X5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE }-a ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSUREqt5 C.0 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 0o 00 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION L r ADDRESS NEAREST CROSS STREET ✓BMWAI W D PARMUNIIP D STATE-A090 D COPOLATION D LOCALIGBO D FEBBliki-M Y W. (�Nueclq ❑ INOMDVl D COMM AGENCY CITY NAME STATE ZIP CODE SITE PHONE p.WITH AREA CODE CA TYPE OF BUSINESS: 2 OISIRIBUTOR ❑ A PROCESSOR ✓Box if INDIAN EPA ID NEATION k of TANK's 1 GASSTATION 3 FARM El OTHER TRUSTVLANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(UST,FIRST) PHONE N 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 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION I MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP ❑ STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boxtoindicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNT'-AGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS I CHECK ONE(i)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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 8 JURISDICTION 4 AGENCY k FACILITY ID R a of TANKS at SITE � 9 / QI L31 CURVE LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA TIO CODE I CENSUS TRACTM SUPERVISOR-DISTRICT CODE BUSINESS PLAN SLED DATE FILED �3 so ?2— YES NO [:] 2 CHECK x PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p BY: G THIS FORM MUST BE ACCOMPANIED BY AT LEAST(7)OR MORE TANK PERMIT FORM `B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INfORMAT10N FORM A(3-2-81{'!17 �1 ^ �``�� DATA PROCESSING COPY '