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STATE OF CALIFORNI0 WATER RESOURCESCONTRAOARD a. f FORM `A': UNDERGROUND STORAGE TANK PROGRAM ,"° ' SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 155 CHANGE OF INFORMATION ❑ 7 RMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAMEA „ De- 4ee CARE OF ADDRESS INFORMATION ADDRESS /�j/// 4 x.-. I NEAREST CROSS STREET &n biN4M 0 PARMBSEN ❑ I'MikGDILY Imo'/ a �j COROPATION 0 ODUIMSENLY 0 fEDB41-AGB4X ❑ INDYIWAL ❑ WIINIV#GBILY CITY NAME STATE ZIP CODSITE PHONE N,WITfi AREA CODE M ? -E u1K_ TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box R INDIAN EPA ID N ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER It of TANICS TRUST LANDS ATION a ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: N ME(UST IRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE /vlC(iyL (Z DoT /olal. NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA DE NIGHTS: NAME(LAST,FIRST) P NE N WITH AREA CODE If. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS —(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITU NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADM$$SHOULD MUSED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY 00® JURISDICTION � AGENCY# FACILITY IDM / N L/TANKS�SITE CUIIRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH MEA CODE � � �_J PERMIT NUMBER PERMIT ALSURCHARGE PERMIT EXPIRATION GATE LOCATION CODE CENSUS TRACT# T CC DE BUSINESS PLAN FILED DATE FILED �-Z T/ YES NO � CHECK# PERMIT AMOUNT FEE CODE RECENT It BY: 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. VJ FORM A(3-2-88)