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STATE OF CALIFORNI00 WATER RESOURCES CONTROL '".A r.. FORM `A': �,��; - `s; UNDERGROUND STORAGE TANK PROGRAM : " �" SITE f T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : �" Z --J COMPLETE THIS FORM FOR EACH FACILITY/SITE ^<.o��" 1 O MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN LY LO D SI E ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 00 FACILITY/SITE AMFx CARE OF ADDR«"„FORMATION W ADDRESS /1 I NEAREST CR/'J/}9 S✓'T'R)EET ✓Sox to Teale ❑ PARTNERSHIP ❑ STATE AGENCY ❑ ORATION ❑ LOCkAGENCY ❑ FEDERAL AGENCY NUIV10UAL ❑ COUNTIAGENC! CITY NAME STATE ZI CODE SITE PHO X,WITH AREA CODE CA �Z�Z d TYPE O Uswess ❑ 2 RIBUTOR ❑ 4 PROCESSOR I ✓Box IT INDIAN EPA ITT XRESE � ❑ 1 GASSTATION 3 FARM ❑ 5OTHER TRUSTLANDSATION ❑ i�//ja AT THIS SIr AT of TANK'TE O1 AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME LAST FIRST) PHONE X WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE X WITH AREA CODE Gf^✓hll S NIGHTS: NAME(LAS .FIRST) PHONE k WITH AREA CODE NIGHT NAME(LAST,FIRST) PHONE X W TH AREA CODE S (lJ'��'-_YA�� j(l A 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box tctftoate ❑ PARTNERSHIP ❑STATEAGENCY❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE X,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME(5/4 CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to lndiwle ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCYCl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE X,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. it. 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION M AGENCY X FACILITY ID X 11 of TANKS at SITE � Q 6a 1 � ooT CURRENT LOCAL AGENCY �FACILITY IDX APPROV BY NAME PHONE X WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERM T EXP I ATIO DATE LOCAT(I�ON CODE CENSUS TgAC7T X SUPER OR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED j GAJ YES NO CHECK X PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X 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. C FORM A(3-2-88) • . L DATA PROCESSING COPY