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OF STATE OF CALIFORN WATER RESOURCES CONTR OARD Zxe` FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; I o L/ COMPLETE THIS FORM FOR EACH FACILITY/SITE `'"F.R� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PERM TLV CLOSED SITE FA' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) A FACILITYISITE NAME CARE OF ADDRESS INFORMATION P A — g 4 ADDRESS NEAREST CROSS STREET ✓CORPORlcea 0 LOCA-AGENCY 0 STATE-AGENp Qr �J ❑ CORPORATION ❑ LOgLAGENC! ❑ FEDERAL-AGENCY I V 0 INDIVIDUAL Cl WUNIY-AGENCY CITY NAME IF STATE ZIP CODE SITE PHONE X,WITH AREA CODE CA fZfJ TYPE OF BUSINESS: 2DISTRIBUTOP 4P ESSOR ✓Boxif INDIAN EPA IDX RESERVATION or If of ❑ 1 GAS STATION ❑ 3FARM 50THER TRUST LANDS ❑ AT THHISIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST IP�NE X WITH AREAI CODE DAYS. NAME(LAST,FIRST) Q�� PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH ARR'EA CODE NIG S: NAME(LAST,FI T) PHONE X WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Q MAILING or S:FREn ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADORE ✓Bax to indicate 0 PARTNERSHIP 0 STATE-AGENCY (y/ ny 11 CORPORATION 11LOCAL0 FEDERAL-AGENCY I O 1 0'I 6 / 0 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME5-ry STATE - ZIP CODE_ PH p,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLINGADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ It. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY X JURISDICTION X AGENCY X FACILITY ID X X of TANKS at SITE ® 10 10 1210 00 10D CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE X WITH AREA CODE -CE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE r ION CODE CENSUSTRACTX SUPERVISOR•DISTRICT CODE BUSINESS PLAN FILED DATE FILED AA 150 � YES � NO � —2 —KX PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X BY � THIS FORM MUST BE ACCOMPANIED BY AT LEAST(7)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. I� FORMA(3-2-88) ��_1� DATA PROCESSING COPY