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STATE OF CALIFORNIP WATER RESOURCES CONTRAOARD -, /SEn� l�f W FORM `A': Z UNDERGROUND STORAGE TANK PROGRAM SITEe I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ® 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE [�1 A I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 00 40 FACIL!jp45fTE NATE CARE OF OGRESS INFORMATION /4 ADDR SNEA ST GROSS STREET ✓Bamirdii 0 PARTNERSHIP 0 STATE AGENCY ❑ IXIRPORATION 0 LOCAL AGENCY EOEAAL ENIX � ❑ INOIVIDOAL ❑ WONTYAGRICY CITY NAME STATEZ ZL�/' SITE PH NE lf.WITH AREA CODE (0126 CA [/' V A 33 3 ESEATION TYPE BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID a p 01 TANK's 1 GAS STATION ❑ 3 FARM E] 5 OTHER TRUST LANDS or Ell"v PV AT THIS SITE b3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST FIRST) PHONE k WITH AREA CODE DAYS. N E LAST,FIRST) _ NE N WITH AREA CODE NIG ME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: N (LAST,FIRST) PHO E N WITH AREA CODE 2n ?7. -STB e II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF 4 FEES INFORMATION MAILING or STREET AD ESS ✓✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION 0 LOCAL-AGENCY ER GENQV W"• 'D �✓ ❑ INDIVIDUAL [I COUNTY-AGENCY CITY NAME O�% STATE� ZIP CODE ��< PHONEklITH AREA CODE I III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box Io Indicale 0 PARTNERSHIP 0 STATEAGENCY 0 CORPORATION Cl LOCALAGENCY0 FEDERALAGENCY 0 INDIVIDUAL 0 COUNTY-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. 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 k JURISDICTION N AGENCY 1t FACILITY ID K N of TANKS at SITE O -7y CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE K WITH AREA CODE S v ICODEBUSINESS PERMIT NUMBER PERMIT APPROVAL DATE MI EXPIRATION DATE 1LOCATIOON CODE CENSUS TRA S PER ISON%IBTRICT PLAN FILED DATE FILED YES NOCHECK M PERMITAMOUNT SURCHARGE A OUNTE RECEIPT M 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 ONL . FORM A(3-2-88) IIIAI/// • DATA PROCESSING COPY