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0 STATE OF CALIFORNIJIt' WATER RESOURCES CONTRCr IOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE C%FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 'Q p COMPLETE THIS FORM FOR EACH FA TTY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 6 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NjW (' f CARE OF ADDRESS INFORMATION (y� � JbNk(i � LI ADDRESS NEAREST CROSS STREET ✓BmbiMnb 0 PAHfMERW 0 STATE AGFh'4Y 0 6 6 7 J Ca'C��f,'1 Gt1.sZ °o 13 `raUM�c ❑ .Ar>ExC AN CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE CA TYPE OF BUSINESS 2 DISTRIBUTOR4 PROCESSOR ✓Box N INDor IAN EPA ID o N of TANKS RESERVATION ❑ ❑ ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ElAT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE Y WITH AREA CODE Sor�Key0y�/9-z�/3o NIGHTS: NAME(LAST,ARST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to irldIcale 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to od,cele 0 PARTNERSHIP 0 STATEAGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE If.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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 d SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION R AGENCY• FACILITY ID R R of TANKS at SITE " 0 3 Gi CURRENT LOCAL AGIVACY FACILITY IDS/ ` APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER G PERMIT APPROVALIDATE PERMIT EXPIRATION DATE LOCATION CO E CENSUS TRACT SUPERRICT CODE BUSINESS PLAN FILED DATE FILED p 1 YES NO CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT P BY: ` n 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) ol0 ,Sv *ft"