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. -.T f O q. �:/.=/R'1., 1��^ -,.y-��. s..n��.YAr.[..'�pj♦'1O_ i Y}�lQy.wi. ... .. STATE OF CALIFORNIA WATER RESOURCES CONTROL bwARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM = " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM F09 E/::.H FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION [_] 7 L LOSEDn F-� ONE ITEM ❑ 2 INTERIM PERMIT E] 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE s N I. FACILITY/SITE INFORMATION & ADDR SS — (MUST BE COMPLETED) W I N FACILITY/SITE NAME /- CARE OF ADDRESS INFORMATION YN ADDRESS NEAREST CROSS STREET ✓Bmti Mete 1:1PAATNIWIP ❑ STATE AGM/ / l/�(J/J ❑ COMORAPON ❑ LOCAL-AGDO ❑ IMOKAGM ❑ INM XXX ❑ WUMY-AGENCY CITY NAMESTATE ZIP CODE SITE PHONE a,WITH AREA CODE Gc CA TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box N INDIAN EPA ID a ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS ATION or ❑ 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 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(I-AST.FIRST) PHONE k WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIPCODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/Box to Indicate ❑ PARTNERSHIP 0 STATE-AGENCY / ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIPCODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ 111.❑ 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 N JURISDICTION# AGENCY N FACILITY ID# #of TANKS at SITE r 0 1 Z37 CURRENT LOCAL AGENCY FACILITY ID# /^ APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT IS ISOR-01ST I ODE BUSINESS PLAN FRED YES NO CHECK# PERMIT AMOUNT SURCHA GE AMO T 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. IN FORM A(32-901 �� "'� DATA PROCESSING COPY