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STATE OF CALIFOR& WATER RESOURCES CONTRR BOARD FORM `A': � ' az UNDERGROUND STORAGE TANK PROGRAM o, o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION / COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY EWPERMIT ❑ 3 RENEWAL PERMIT �CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM 21NTERIM PERMIT ❑ 4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE w' t'1 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INF ORM ION 6CLADkE k) to S C LE� 952:9 DR'jESS NEAREST CROSS Sele ❑ PARTNERSHIP ❑ STATE-AGENCY ..J TAN LOCAL AGEN(A ❑ FEDERALAGENCYL ❑ COUNTY-AGENCYSTATE SITE PHONE#,WITH AREA CODE QCA WE TYPE OF BUSINESS ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # IF of TANK's ❑ ION 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS N ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) i PHONE WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE It WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. ❑ it. E] 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE m � � I I Z5 13 I q ] 101 DC) 3 CURRE T LOCAL AGENCY FACILITY ID# APPROVED BY NAME^ PHONE#WITH AREA CODE rry I J PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION GATE LOCATO iODE CENSUSTRAC# SUPERVISOR-DISTRIC CODE BUSINESS PLAN FILED DATE FILED 2 I✓II YES NO 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 NLY. FORMA(3-2-88) DATA PROCESSING COPY ,