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STATE OF CALIFORNI*, WATER RESOURCES' CONTRAIRD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ' mo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o COMPLETE THIS FORM FOR EAC FACILITY/SITE `^��•oa�`" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT IV5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1S 3 � I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) T FACILITY/SITE NAME CARE OF ADDRESS INFORMATION S �o ADDRE NEAREST CROSS STREET ✓8w to iMirale Cl PARTNERSHIP ❑ STATE AGENCY /') ❑ CORPORATION Cl LOCAL AGENCY ❑ FEDERAL^V ❑ INDIVIDUAL ❑ WUNIVAGENCY CITY NAM STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA 5120 TYPE OF BUSINESS: ❑ p ISTRIBUfOR ❑ 4PROCESSOfl '/Box if INDIAN EPA ID p #of TANK'# ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUSRESETLANDSATION o ❑ ATTHIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(IASE FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION is rPd MAILING or STREET ADDRESS ✓Sox to indicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTYAGENCY CITY NAME ST ZIP DE 2� PHONEN,WITH AREA CODE ,��r C� S Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,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 1f JURISDICTION iY AGENCY# FACILITY ID R N of TANKS at SITE w I I I m 1 el I(11:� CURRENT LOCAL AG6fIC�l1CIL17Y Ip M�� APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER I(��/'1 L/��I(✓^/^J PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ELOCATIONCODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILIPYES NO 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-SB) DATA PROCESSING COPY