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STATE OF CALIFORNIA- WATER RESOURCES CONTRO BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE � o ACILITY/SITE, INFORMATION and/or P RMIT APPLICATION } " / �- cc COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑!-REAMI CLOSED SITE 1% ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE c QT I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) + FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION GyoR LnrG ADDRESS NEAREST GROSS STREET ✓So wNb'dle 0 PARTNERSHIP D STATE AUNU 2 ^'/� 1/� D COPFOMiDN Cl LOCA AGENCY D FEDERAL AGENCY I N�Z/O V\ ❑ INDIVIDUAL ❑ CWND AGENCY CITY NAME STATE A ZIP CSITE 4�p- WITryAREA CODE TYPE OF BUSINESS: F—] 2 DISTRIBUTOR F__] 4 PROCESSOR I/Box if INDIAN EPA 10.NESEh ❑ E] ❑ TRUSTAT THIS SITE EMERGENCY ATION Or ❑ 1 GAS STATION 3 FARM 5 OTHER EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,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 II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMAT ION MAILING or STREET ADDRESS ✓Box to mmuie D PARTNERSHIP Cl STATEAGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION Cl LOCAL AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE 11)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ III.❑ 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 �OUNI JURISDICTION N AGENCYTIF FACILITY ID N N of TANKS at SITE L I �� = 1010 U 0 CURRENT LOCAL AGENCY F CILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE G LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Y J Z YES NO Cv CHECKN / PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE ❑RECEIPTY ❑ BY. C_l THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNI FcS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) .� DATA PROCESSING COPY r+