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TATE OF CALIFORNI90 WATER RESOURCES CONTROROARD SEP�• •rNA FORM `A': _ 1 l N� Z UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) co FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS `y� � ) //n NEAREST CROSS STREET N/Go.b MM ❑ PARTNERRHR ❑ STATEAGENCY �� (/V �J�� CiT>F`.1 M eld� ❑ INDIVIDUAL ClPAUNIVAGENCf L AGENCY ❑ �EAAbAGENp CITY NAMESTATE ZIP CODE SITE PHONE#.WITH AREA CODE 6 CA TYPE OF BUSINESS: ❑ 2 TRIBUTOR ❑ 4 PROCESSOR ✓Bo if INDIAN EPA ID # It of TANK's RESE ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TTRUSTVATION LANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAt (LAST,FIRST) PHONE�ITH=REACOf0 DAYS ME(LAST,FIRST) ZlPHONE#WITH`��CODE NIGHTS. NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS NAME(LAST F STI PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME /1 p ® CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS AT/} ✓Box laindicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME 5 r` --LCARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/B..W,,d,cale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl 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. ❑ 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# JURISDICTION# AGENCY# F LITY ID# If of TANKS at SITE EO 4 v 1 CURRENT LOCAL CY FAC ITY4Y.ID# yy APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER ATE PERMIT EXPIRATION DATE FORM CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINES,PUN FILED NO ❑ DATE FILED_ 'e� PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. O '\ DATA PROCESSING COPY -