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,i STATE OF, CALIFORNIA WATER RESOURCES CONTROL BOARD �E FORM `A': .:UNDERGROUND STORAGE TANK PROGRAM ro FI SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITEc x I C3 �lFOpNiP I MARK ONLY ❑ i NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION NT Y CLOSED SITE iV I ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E]6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) c i FACILITY/SITE NAME CARE OF ADDRESS INFORMATION a^n/H Cetodit&fS Ga ADDRESS NEAREST CROSS STREET ✓Bar to mdmte ❑ PARTNERSHIP ❑ STATE-AGENCY D `I V l� V'N✓moi ❑ COHPGRATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY CCJJ KK ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE' SITE PHONE#.WITH AREA CODE CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR �PoTHER ESSOR ✓Box if INDIA EPA ID #RESERVATION or #of TANK'6 I GAS STATION ❑3 FAAlA TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) I DAYS: NAME(LAST,FIRST) PHONE H WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,IRRSTI PHONE#WITH AREA CODE I I Il. PROPERTY OWNER INFORMATION &ADDRESS -'-- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate © PARTNERSHIP ❑ STATE-AGENCY I ❑-GORPOHATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY fE ❑ INDIVIDUAL ❑ COUNTY-AGENCY �I CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE a i 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 it,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: I. ❑ 11. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNOER 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# JURISDICTION# AGENCY# FACILITY ID# #o TANKS et SITE } ------ Fl I j 10.10Ili1,0101 CURRENT LOCAL AGENCY FACILITY D# APPROVED BY NAME PHONE II WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I LOCATION CODE CENSUS TRACT I SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 2 3 Z YES ❑ NO ❑ ?j lj3 �C� t I 1 CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT q L �� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1).OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. } �FORM A(3-2-88) '• t. I \4 DATA PROCESSING COPY