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STATE OF CALIFORNIP WATER RESOURCES CONTROL OARD 5f.•'"'` ` FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EZr5 CHANGE OF INFORMATION ❑ 7 PERMANENT Y CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE N n CARE OF ADDRESS INFORMATION Gz� l/GLL 05;so /Fe in ADDRESS /� c\-(} NEAREST CROSS STREET ✓Badovdictle 0 PABTNEBSIIIP 0 STATE-AGENCY V V t �,J/ F✓ Q. 0 LOCAL AGENCY 0 EMIL AGENCY CITY NAME ® STATE CA ZIP COD�7 11 SITE PH Ie ITH AR ODE TYPE OF BUSINESS: 2 T5ArBUTOR 4 P ✓Box if INDIAN EPA ID N ❑ 1 GASSTATION FARM ❑ 5 OTHER TRUST LANDS 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 A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It 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 MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY 0 INDIVIDUAL 0 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 ✓Be.to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL 0 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION M AGENCYIN FACILITY ID N M of TANKS N SITE i I d o �lo 1 o 010 171 CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE N WITH AREA CODE LV2-b PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION O CENSUS TRACT A! SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO 7/ -O/ CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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(3-2-68)