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STATE OF CALIFORNIA WATER RESOURCES CONTRAOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM £ R�' SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION roo 0 03/ COMPLETE THIS FORM FOR EACH FA ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT lyrb CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"* ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W O7 FACILITY/SITE NAME ^y CARE OF ADDRESS INFORMATION J AODflESSL NEAREST CROSS STREET ✓Sm to iraLme [I PARTNERSHIP ❑ STATE AGENCY El11 A / LZJ S CORPORATION LOCAL AGENCY ❑ FEDERALGENCY JJ / ❑ INDIVIDUAL ❑ COUNTY- AGENCY CITY NAME / STATE ZIP CODE SITE PHONE R.WITH AREA CODE ;GflL�G CA TYPE OF BUSINESS: ❑ P DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a RESERVATIONor M of TANK's ❑ I GASSTATION �SFARM ❑ 5OTHER TRUST LANDS ❑ ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA COOE NIGHTS: NAME(LAST.FIRST) PHONE M 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 indicate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A,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 0 FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE u,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. ❑ If. ❑ If. ❑ 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 k JURISDICTION Al AGENCY AI FACILITY ID k k of TANKS at SITE m = = 1 1 1411 1 & CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE K WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CO E CENSUS 7TRA-C'TT k SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE 2ICED /„ a�aa YES NO CHECK M VWW/ PERMIT AMOUNT 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. M A(3-2-88) J ��•� 0 DATA PROCESSING COPY