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STATE OF CALIFORNIO WATER RESOURCES CONTROBOARD .seri r"e FORM 'A': ' ' UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE O 7_p 70 / /9- MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 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) FACILITY/SITE NAME ` , CARE OF ADORE I FOR ATION / G, s 1/ i ADDRESS NEAREST CROSS STREET ✓BmWoNcie 0 pARTNERS41P 0 STATE AGENCY ❑ COI)WTION ❑ LOC&AGENCY 0 FEDERAL AGENCY 0 INDIVIDUAL 0 COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE A.WITH AREA CODE CA TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4PROCESSOR -/Box if INDIAN EPA ID N ❑ of TANK's 1 GAS STATION 3 FARM ❑ 5 OTHER RE VLANDS ATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE G7 ' NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S�"F a5 MAILING or STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION ❑ LOCALAGENCY0 FEDERAL-AGENCY 0 INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS — (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 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION R AGENCY R FAC 3TC M of TANKS of SITE 3 ' URRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE G/1-c/6 2— PERMIT PERMIT NU APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ,,SS �23. 2—"3 2.� YES NO Zj �V 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 ONLY. FORM A(3-2-8B) 0 •