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STATE OF CALIFORNIPr- WATER RESOURCES CONTROL'mOARD ge�� yF a FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 19 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION U of Y � - ' > ADDRESS NEARESTCROSS ST EET ✓ WidWe D PMT*T4HW D STATEAGENLY 50 o C tl UC ❑ DM°�L 11 tm o ❑ �W AGFH CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE sfor-00 rJ CA Q52o6 209r 2-0 00 TYPE OF BUSINESS'. ❑2 DISTRIBUTOR ❑ d PROCESSOR ✓BoN if INDIAN EPA ID n RESERVATION orS of TANK's ❑ I GAS STATION ❑ 3 FARM El OTHER TRUST LANDS El THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE If 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 INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION c �p MAILING or STREET ADDRESS D✓Sod to,ndicate D PARTNERSHIP D STATE-AGENCY O D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY S` INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE II,WITH AREA CODE k 5206 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDIIEBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 111. 03/ 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 R JURISDICTION R AGENCY R FACILITY ID R R of TANKS at SITE d 101 ( I 1 15 12] CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE EL ERMIT APPROVAL DATE PERMIT EKPIRATION DATE TRACT* SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED 0ATEFILED vS" YES NOrUNT SURCXARGE AMOUNT FEE CODE RECEIPT 0 Y. 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. ORM A(3-2-88) CA L--)