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STATE OF CALIFORNht WATER RESOURCES CONTR&BOARD 9E'•u JMf FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V ma Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o 10 COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I� ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE6�' -4 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) A FACILITY{61)E NAME CARE OF ADDRESS INFORMATION ADDRSSfeV/ NEAREST CROSS STREET ✓Bwb le ❑ PARTNERSHIP CJ STATE AGENCY SNP R4i'ION ❑ lOG1AGBlC/ ❑ FE➢EML-AGENCY NIGUAL ❑ COUNTY-AGENCY CITY NAMESTATE ZIP CODE SITE PHONE N.WITH AREA CODE cCA X33 TYPE OF BUSINESS: E 2,9&18UTOR ❑ 4I PROCESSOR '/Box it INDIAN EPA ID p RESERVATION or F of TANK'a ❑ 1 GAS STATION [213 FARM E] 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE H. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M.WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS Be.✓ tcindicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A,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. II. ❑ IIL❑ 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 M JURISDICTION N AGENCY B FACILITY ID N K of TANKS at SITE = = = 1 1 14oza CURRENT LOCAL AGENCY F�ID 1L APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER S PERMIT APPROVAL DATE LCODE TION DATE LOCA;IOj(CODE CENSUS TRACTN SUPERVISOR-DISTRICT CODEN FILED DATE FILE NO � �g CHECK M PERMIT AMOUNT SURCHARGE AMOUNT RECEIPT Y 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. FORM A(3-2-88) �Fallow DATA PROCESSING COPY �r