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r,�'4^•--•�.--.'..r.�.-,—s*•mr-rS..rrvrv.�v.erra'N`Rwrr-rn.—..y'�F'*xr�PlPae.,T,`Y,.,y�-yr�.......i.,.. .,,.. e. .. 'A�l� a�^{' 'f i /SOF I STATE OF CALIFORNIP WATER RESOURCES CONTRO&ARD W. FORM `A': UNDERGROUND STORAGE TANK PROGRAM All, SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1© I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) FACILITY TE NAME C CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Box IO PXate ❑ PARTNERSHIP ❑ STATE AGENCY C" ^ 1 ❑ CORPORATION ElLOCAL AGENCY Cl FEDERAL /50 0( ^/, ❑ INDIVIDUAL Cl COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE 40 CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box if INDIAN EPA ID # If Of TANK'# RESE 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS D ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYSNAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) 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 MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY 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: I. ❑ I. ❑ 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# #of TANKS at SITE m CUR®RENT LOCAL AGE7Y FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE A � PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# ODE CENSUS TRACT# SUPE RVISOR•DISTRICT CODE BUSINESS PIAN FILED DA FI/yD� VES ❑ NO ❑ g' bb PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: 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. FORMA(3-288) • DATA PROCESSING COPY • IS