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,.. !. ;c1t'-^t::,s. .:;m'!R?+mNr.:.?�a.�-,r0.}•yxn-i.°�T--+.�m�..--r-•v-:_..... STATE OF CALIFORNIA WATER RESOURCES CONTROAARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ' dal Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION TLY LOSEDSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 11 �� IV 00 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N FACILITY/SITE NAME C11 CARE OF ADDRESS INFORMATION W ADDRESS VL NEAREST CROSS STREET ✓Eariantlxae ❑ PARTNERSHIP ❑ STATE AGENCY I Lv ❑ CORPORATION ❑ LOCALAGEAC.Y 11 FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE TYPE OF BUSINESS: 2 DISTRIBIIWR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID x 5 ❑ I GAS STATION ❑3 FARM ❑ 5 OTHER RESERVATION of ❑ X of TANK's TRUSTLANDSAT THIS SITE D EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE P WITH AREA CODE Ui NAME(LAST,FIRST( PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNT'-AGENCY CITY NAME STATE ZIP CODE PHONE N.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 ❑ FEDERAL-AGENCY El INDIVIDUAL 13COUNTY-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. ❑ it. ❑ 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 COJU�E] =NT/Y# JURISDICTION M I AITTGENCYII# FACILITY ID# It of TANKS at SITE ' TFT/ CURRENT LOCAL AGENCY FACILITY IDN / APPROVED BY NAME PHONE At WITH AREA CODE � I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N O SUPERVISOR-DIST�ICT�DE BUSINES Y 5 N❑FILED NO ❑ DATE FILED 3- CHECKII v„ PERMIT AMOUNOTT SURCHARGEAMMO/UUNNT FEE CODE RECEIPT# BY: 11 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(!)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. a" 1 FORM A(3-2-88) DATA PROCESSING COPY / AA