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STATE OF CALIFAIA WATER RESOURCES COROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE OFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARKONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT El❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETFnl eEPL M1f. o; C9LIFo1 NSP SITE FACILHY7SIT NA /E ARE OF DRESS INFORMATION CARE OF ADDRESS INFORMATION , TWL' CARE F DDRESS INFORMATION ✓ Bax to ino.m. ❑ PARTNERSHIP ❑ STATE -AGENCY ADDRESS nn �. �V A NEARE TCROG(SSTREET ✓Hm loiMicale ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ •(Jx / I L+ p ' LJJGI'f��OLl/"'� LOCAL DERAL A ENLY CITYE APPROVED BY NAME STATE ❑ INDIVIDUAL ❑ COUNNAGENCI CITU NAM �� '❑ C STATE ZIP C E CA ITE PHON p,WIT EA CODA - 33 CENSUS TRACT p Q(� 3 TYPE 0 B(/�U'S�I•NESS. p DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID N AS STATION ❑ 3 FARM ❑ 5 OTHER TTRUSTRESERYATION LANDS D ❑ / l li AT THIS SITE 03 EMERGENCY CONTACT PERSON (PRIMARY) FEE CODE RECEIPTp EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE p ITH AREA CODE �Fr., DAYS: NAME (LAST, FIRST) PHONEY W H AREA CODE (J p U- f SIA NIGHTS: NAME (LAST, FIRST) PH WITH AREA CODE NIGHTS. NA E (LAST, FIRST) PHONE k W H AREA CODE P43es-�!z P II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST RF nnIU D11 FTcn1 III. TANK OWNER INFORMATION & ADDRESS — (MUST RF cnMD1 FTFn9 NAME JURISDICTION # --A CARE OF ADDRESS INFORMATION ^ NAME- i4 I CARE F DDRESS INFORMATION ✓ Bax to ino.m. ❑ PARTNERSHIP ❑ STATE -AGENCY MAIL) rSTREETA $S C) A ✓Box roindicale ❑ PARTNERSHIP ❑ CORPORATION ❑ ❑ STATE -AGENCY •(Jx / I L+ LOCAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY ❑ F OERA -AGENCY CITYE APPROVED BY NAME STATE ZIP CODE PHON , ITH AREA COD) C Cts 33 III. TANK OWNER INFORMATION & ADDRESS — (MUST RF cnMD1 FTFn9 NAME JURISDICTION # AGENCY p CARE OF ADDRESS INFORMATION M of TANKS at SITE MAILING or STREET ADDRESS ✓ Bax to ino.m. ❑ PARTNERSHIP ❑ STATE -AGENCY bo TFF6-1 ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERALAGENCY❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE p, WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. F, II. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION # AGENCY p FACILITY ID N M of TANKS at SITE bo TFF6-1 o CURRENT LOCAL AGENCY FACILITY ID p 2S APPROVED BY NAME PHONE p WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT p SUPERVI OR -DISTRICT CODE BUSINESS PLAN FILED FILED YES NO ,DATE CHECKk PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTp BY: ass' THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FORM `B' APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA (3-2-88) 41 DATA PROCESSING COPY 0 0