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R041-& .23 7 -Ji� 97 de- c '4 STATE OF CALIFORNik- WATER RESOURCESCONTROL-9OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM =" " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; COMPLETE THIS FORM FOR EACH FA LITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I..A. ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) A F-� FACILITY/SITE NA!E.. CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET lades" ❑ PARINERSHIF ❑ S1ATEAGE0 o0m0MrI0N ❑ LOMAGEIKY ❑ FEOERA-AGE10 l/ Cl INDINDUAL ❑ COUNN AGENCY CITY NAME STATE ZIP CODE k SITE VHONE 4,WITH AREA CODE j ki& CA JS`27.5_0 TYPE OF BUSINESS: 2DISTRIBUTOR ❑ 4PROCESSOR -/Box if INDIAN EPA IDN RESERVATION NoI TANK'N [:]❑ I GASSTATION 3 FARM ❑. S OTHER TRUSLANDS or ❑ / /W AT THIS SITE 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 i2 NIGHTS: NAME(LAST,FI T) NE 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 RMATION v MAILINGor TBEET ADDRE RC✓ O, A ❑ RTNERSHIP ❑ STATE-AGENCY CORPORA N 13-LOCAL-AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL 13 COUNTY-ADEN CY CITY NAME, STATE ZIP CODE PHONE k,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME ' CARE OF ADDRESS INFORMATION it MAILING or STREET ADDRESS %/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. RrIII.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY K JURISDICTION k AGENCY M FACILITY ID R Al of TANKS of SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA JODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO — CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: I 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(3-2-98) *law DATA PROCESSING COPY ,,,,/