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I STATE OF CALIFORNIP WATER RESOURCES CONTROLBOA FORM `A': RD 'a SITE UNDERGROUND STORAGE TANK PROGRAM n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION lJ COMPLETE THIS FORM FOR EACH FACILITY/SITE C'�IIpOPNI FMARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT y1�A ONE ITEM 5 CHANGE OF INFORMATION 7 pERMANENTLV CLOSED SITE `y 2 INTERIM PERMIT A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE •� I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME W Tm n P _ CARE OF ADDRESS INFORMATION in I W ADDRESS ZNEAREST CROSS STREET ✓Pq bMiGle ❑ PggiNEA lP CJf �1�i ❑ CGAPoAAiIGN ❑ LGCALAGENGY ❑ EEGEAALAGENCY CITY NAME ❑ INONIGUAL ❑ CWNN AGENC/ � STATE ZIP CODE SITE PHONE q,WITH AREA CODE TYPE OF BUSINESS: p DISTRIBUTOR 04 PROCESSOR '/Box it INDIAN EVA p pA E] I GASSTATION 3 FARM - EOTHER RESERVATION ar ❑ #oI TANK'e /� TRUST LANDS / EMERGENCY CONTACT PERSON(PRIMARY) A7 THIS SITE DAYSNAME(LAST,FIRST) EMERGENCYCONTACT PERSON(SECONDARY) : PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST FIRSTI PHONE It WITH AREA CODE [L PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) LNAMECARE OF ADDRESS INFORMATION G or STREET ADDRESS ✓Baato RATIteP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALA ❑ FEDERAL-AGENCY ME El INDIVIDUAL O COUNTY-AGENCY STATE 21P CODE PHONE a,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toinftate ❑ PARTNERSHIP ❑ STATE ❑ CORPORATION ❑ LOCAL-AGENCY AGENCY CITY NAME ❑ INDIVIDUAL ❑ COUNTY- FEDERAL-AGENCY gGENCV STATE ZIPCODE PHONE q,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: 1. F-- II. El 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# ED � FACILITY ID# #of TANKS at SITE C� Z CURRENT LOCAL AGENCY FACILITY ID# 23 APPROV.... .... PHONE#WITH AREA CODE I- PERMIT NUMBER ' PERMIT APPROVAL DATE PERMITEX DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED Z�: -� DATE FILE CHECK MYES E] NO F] PERMIT AMOUNT SURCHAR AMOUNTL/ ' FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST )OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION , I FORMA(3-2-88) V DATA PROCESSING COPY