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STATE OF CALIFORNIA WATER RESOURCES CONTROWARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION LY 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 tA 1 � CA if ADDRESS NEAREST CROSS STREET ✓Box to Wc* ❑ PARTNERSHIP ❑ STATE-AGENOt ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY _ D ❑ INOMMAL ❑ COUNTY-AGENCr CITY NAME L A y S7AT�A ZIP COC / SITE PHONE Al.WITH AREAiG�, F—] R ✓ E�� TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 PROCESSSOBoz it IINI?IAN EPA ID 1+ (f(J (v' ^�;/y/' N of TANKK's ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTRESERVATIONLor ❑ AT THIS SrTE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE 11. 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 ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 9,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS_ - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Odicale ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY 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: L ❑ II. ❑ II(.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE, 1S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY [NUMBER JURISDICTION# AGENCY# FACILITY ID M M of TANKS at SITE = I 1- -Ll El I I LLI I I IL3�Lr_l I I T 1-31 ENCY FACILITY IDN APPROVED BY NA�M�E f PHONE N WITH AREA CODE PERMIT OVAL DATE PERMIT EXPIRATION OATS CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED TDATE FILED YES ❑ NO ❑ 1 zU PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECt IPT N BY: THIS FORM DUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B`APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON { FORM A(9-12-88) ( -1 9, 1 ^16