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STATE OF CALIFORNIA WATER RESOURCES CONTROLIARD !sf" FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �, e COMPLETE THIS FORM FOR EACH FACILITY/SITEZ00000, -"-�" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE A ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q / I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) a FACILITY/SITE NAMECARE OF ADDRESS INFORMATION ( ADDRES /"� NEAR TCROSS TRE ET I/BU lo,,daile 11 PARTNERSHIP E STATE-AGENCY (/�✓ 11WRPORATION ElLOCALAGEHCY El FEDERAL AGEND CI INDIVIDUAL 11 COUNTY-AGENCY CITY NAME S STATE ZIP CODE SITE PHONE I WITH AREA CODE J CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 1❑ 44,,PRROOCESSOR I/BOX if INDIAN EPA 10 it RES❑ ❑ Imo''' TRUST LANDS ATION O ❑ #of HIS SITE I GAS STATION 3 FARM THEA AT THIS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: N ME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE LAL NIGHT : NAME(LAS IRST) PHONE WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION C MAI o STREET ADD S ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY x 0 a O ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME ST TE ZIP ODE PHONE#,WITH AREA CODE III. TANK OWN& INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Paw" MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL Cl COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#,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: 1. ❑ 11. ❑ 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# FACILITY ID If IF of TANKS at SITE ml6oa I tf I k Iq I 10 © moo CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE a s �- \t PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ,v LOCATI N C DE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED �\ YES ❑ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTING ❑ �oB THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS T IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-811 DATA PROCESSING COPY