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^�i S — 3cf/ -0-1, STATE OF CALIFORNI,#r WATER RESOURCES CONTRLv%eBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 1® FACILITY/SITENAME CARE OF ADDRESS INFORMATION M - Sag" ADDRESS NEAREST CROSS STREET ✓mitamicca ❑ PARTNERSHIP 0 UAH AGENCY N l ❑ CO rloN ❑ LOCAL.ACEN. ElFEDERAL AGENCY (i MIT ❑ COUNn_AGENDY Qj moi► it CITY NAME STATE ZIP CODE SIJE PHONE N,WITH AREA CODE CA (209J 2 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Boz B INDIAN EPA ID N #of TAN is RESERVATION or ❑ 1 GAS STATION ❑ 3 FARM ❑ 5OTHER TRUST LANDS ❑ ATTHISSITE i EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME LAST,FIRST) PHONE N WITH AREA CODE NIGHTS' NAME(I-AST,FIRSTK I, PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) HONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or T A S ✓Box to d to 0 PARTNERSHIP 1] STATE-AGENCY ❑ RAT ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY DIVIDUAL 0 COUNTY-AGENCY CITY NAME OF STATE ZIP CODE PHONE 4,WITH AREA CODE Z - 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) SII NAME —� CARE OFADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY i CITY NAME STATE ZIP CODE PHONE N,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. ❑ IL ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. I APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION p AGENCY# FACILITY ID# X of TANKS M SITE u Oct G / 3 1010C) / CURRENT LOCAL AGENCYY F�LITY ID# APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION GOD CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED YES NO / . CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 ON I� FORMA(3-2-88) /\ DATA PROCESSING COPY lu/