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STATE OF CALIFORNIP WATER RESOURCES CONTRJRIOARD a FORM IA': UNDERGROUND STORAGE TANK PROGRAM �o SITE, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT F-] 3 RENEWAL PERMIT F 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓CORPOReall?ATION 0 pAnowLOCAI.AGEN 0 FEDTE ERAL ENCY AGENCY G`f 4 Q INDcDANDUAnoN 11 cavi ACD a ❑ F anLADENa CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P R ✓Box if INDIAN EPA ID N RESERVATION or M of TANK's ❑ 1 GAS STATION ❑ 3 FARM THER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON [PRIMARA EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST.FIRST) PA7 N WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHON WITH AREA CODE NIGHTS: NAME(IAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDR S — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓BOx to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME Ns STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE"COMPLETED) NAME CARE FADDRESS INFORMATION MAILING or STREET ADDRESS ✓So o indicate 0 PARTNERSHIP C STATE-AGENCY ❑ COR RATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVI AL 0 COUNTY-AGENCY CITY NAME STATE 21P 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 NOTIFICAT16H AND BILLING: I. ❑ If. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF M KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION B AGENCY S FACILITY ID K B of TANKS St SITE a[� 16 1 6 I / 1 16o0 () CURRENT�QCAL AGE CY FACILITY IDM APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER CxC PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAT N CODE CENSUS TRA SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FI D /� . �C 0 v _ �� YES NO --Q ��/ CHECKS PERMIT AMOUNT 1✓ SURCHARGE AMOUNT FEE CODE RECEIPT k 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. FORM A(3-2-88) J