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np++rn.q�,•�t7^r"'S;R7`s?'�..:�:;�E�;y`�7�TTd.'E,'.Pgiq7}fi"!AN'aryt�.piy�,'t:vggR•.A�i�*sl ,,.:�..,w„�n,., - .. STATE OF CALIFORNIA” WATER RESOURCESCONTROL76ARD p FORM A': UNDERGROUND STORAGE TANK PROGRAM = � o SITE a FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Im I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION N ADDRESS 2 NEAREST CROSS STREET ✓Bo e ❑ PARTNERSHIP ❑ STATE AGENCY co J PoMTION ❑ LOCAL UNRA EN ❑ NOERAI AGENCY INOMOUAL ❑ CAUNIY-AGENCI CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA � 23-Z23� TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PR ESSOR ✓Boz A INDIAN EPA ID #RESEp TANK. E:] 1 GAS STATION ❑ 3 FARM HER TRUST W LANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LASE RRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NA (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME / CARE OF ADDRESS INFORMATION I MAILING or STREET ADDRESS ✓Box to indicate Ll PARTNERSHIP 13STATE-AGENCY / ClCORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY (Q� ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE I$,WITH AREA CODE 1 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME - CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to'rocale Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPO ION ElLOCAL-AGENCY IllFEDERAL-AGENCYC3 I'D", ❑ COUNTY-AGENCY CITY NAME rN IZTATE ZIP CODE PHONE N,WITH AREA CODE L.. IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SIN 0ULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I.T. I ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRt-Vi AND CORRECT. APPLICANT'S NAME(PRINTE TORE) DATE LOCAL AGENCY USE ONLY COUNTY p JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE x 5/ = 06 , o CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#All AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIONC E CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED D YES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTIf 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) %p► DATA PROCESSING COPY I-W