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STATE OF CALIFORNIA`" WATER RESOURCESCONTROLiOARD FORM A: UNDERGROUND STORAGE TANK PROGRAMo Z SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 FERMAN NNT�LY CLOSED SITE F"A ''I ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a N 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION plj ADDR 7 NEAREST CROSS STREETbi ✓ d— ClPARNEASHIP ❑ 5TATEAGENCY Go �O'TION ❑ LDCAMGENCY ❑ FEDENALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE CA S'ao5 �o - o6) TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID x X of TANK4 RESERVATION or /I O'THIS SITE ❑ 1 GAS STATION E::] 3 FARM OTHER TRUST LANDS ❑ f W EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHO E N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE W y' ' u a q - `Fo NIGHTS. NA ST.FI T) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAMCARE OF ADDRESS INFORMATION ✓ MAILING or EET ApORESS x t indicate 13PARTNERSHIP ❑ STATE-AGENCY CORPORATION 11 LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY AME "ATE� ZIP ODE PHONE#,WITH AREA CODE K III. 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 I O ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME ST PT� ZIP C0 PHONE k,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. 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 COUNTY P JURISDICTION N AGENCY R FACILITY ID If If of TANKS at SITE Rul E= © d / " ; 3 oo © a CURRENT CAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE Lp er PERMIT NU PERMIT APPROVAL DATE PERMIT EXPIRATION DATE bLOCATION CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED YES ❑ NO ❑ CME # PERMIT AMOUNT SURCHARGEAMOU FEE CODE RECEIPT# BY: 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. FORMA(3-2-88) �,. DATA PROCESSING COPY