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STATE OF CALIFORNIO WATER RESOURCES CONTRIPBOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =" o Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN D SITE ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) F-i FACILITY/ NAME CARE.O'F DRESS INFORMATION ADDRESS r (,f ,EST STREET �OAPOIIAiION ❑ PARTNERSHIP AGENCY Cl STATEAGENCYAGENCY /% Q INOMOUAL ❑ COOMY AGENCY CITY NAME// 1..1 STATE ZIP�ODF� �D SITE PH E H,WITH]�A CODE LAI) 1 CA �jl S SE TYPE OF BUSINESS: p DISTRIBUTOR011-mOCESSOR ✓Box if INDIAN EPA/ID/p #of TANK's ❑ 1 GAS STATION ❑ 3 FARM ` 5 OTHER TRUSTTVLANDS ATION or ❑ AL 114 AT THIS SITE(l I EMERGENCY CONTACT PE SO (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAY NAME(LA T,FIRST) x PHONE p WITH AREA CODE DAYS Pf.ME(IAST.FIRST) P p WITH AREA CODE S NIGHTS: NAME( .S FI - P NNITHA Ep RZ GOO DE NIGHT : NAME(LAST FIRST( PHIDNE WITHAREACODE 11. PROPERTY O INFORMATION & ADDRESS — (MUST E COMPLETED) NAME CARE OF ADDRESS INFORMATION S /4 MAILING or STREET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME A CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box la Intllcale Cl PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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: 1. it. ❑ 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 as COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE D 3 1 CURRENT LOCAL AGENCY FACILITY ID# APPR VED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERIAT EXPIRATION DATE LOCATION CODE CE-2-3` T#0 SUPERVISOR-DISTRICT CODE BUSINESPLAN F❑ILEO NO / DATE FILED CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# CrJ( ///T/l/_/BY:: L. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-SB) �,,` _ lb DATA PROCESSING COPY