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STATE OF CALIFORNI40 WATER RESOURCES CONTROROARD FORM 'A': SITE UNDERGROUND STORAGE TANK PROGRAM =��' �m �/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -°� �• 1 C- COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT �3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ PER LOBED 517E 2 INTERIM PERMIT q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) to FACILITY/ TE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Box 10 riAidle ❑ PARTNERSHIP ❑ SiATE AGENCY N ❑ CORPOFATON p��.�.�^e��AGENCY ❑ FEDEPAGEND Y -11 CITY NAME ❑ INDIVIDUAL LJ COYFtt AGENCY (A STATEZIP CODE`_ SITE PHONE It WITH AREA CODE —I TYPEOFRUSINESS CA ✓� 2 DISTRIBUTOR 4 PgOCES30R ✓Bax if INDIAN EPA ID a 1 GAS STATION 3 FARM OTHER RESERVATION or ❑ #of TANK'# / TRUST LANDS AT THIS SITE r EMERGENCY CONTACT PERSON(PRIMARY) DAYSEMERGENCY CONTACT PERSON(SECONDARY) : NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. AME(LAST,FIRST) '61-9436/IPHONE p WITH AREA CODE NIGHTS:-NAME(LA ,FIRST) PHME N WITH AREA CUUFE IGHTS: NAMle AST,FIRST PHONE WWITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET A RESS .nq ✓Box to intlicale ❑ PART ERSHIP ID CDR -AGENCY ❑ FEDERAL--AGENCY CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE W,WITH AREA CODE 7,7D III. TANK OWNER INFORMINTION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box W intlicale ❑ PARTNERSHIP El CORPORATION 11LOCAL-AGENCY Cl STATE-AGENCY CITY NAME 1:1 INDIVIDUAL Ll COUNTY AGENCY FEDERALAGENCY STATE ZIP CODE PHONE 4,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. 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,I S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION R AGENCY A, FACILITY ID If It of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID k APpppyED BY NAME r_ O PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED _ DATE FILED e� 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 ONLY. FORM A(3-2-88) Cv\v' 0 DATA PROCESSING COPY