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or STATE OF CALIFORNIJO WATER RESOURCES CONTR ARD FORM 'A': 1, UNDERGROUND STORAGE TANK PROGRAM SITE ';) All_ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT -_ ERMITHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE / 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAM / CARE OF ADDRESS INFORMATION ADDRESS O NEAREST CROSS STREET ✓Pm 10 r6uIe ❑ PARTNERSHIP ❑ STATE AGENCY L' /• l� [I WfBORAPON ❑ LDGLLAGENCY El FEDERAL AGE/KK Z 6- /� ❑ IWNDUAL ❑ COUNTY-AGENCY CITY NAME /s� STATE 21P CODE SITE PHONE p,WITH AREA CODE L!/ CA TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID N _ M of TANMF ESE❑ 1-1 I GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTYLANDS ATION or ❑ ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to md,cate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTY-AGENCY 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. ❑ II. ❑ 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 M JURISDICTION B AGENCY k FACILITY ID M B of TANKS at SITE m � � 0 () 0 CURRENT LOCAL AOENQY FACILITY ID N_� ' APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER 1(V/A'A,/f('I/ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DI CODE BUSINESSPLAN NO N FILED ❑ DATE FILEDS '� Ice CHECK Al 9 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BYa^J THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATIONONLY.. FORM A(3-2-88) J