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STATE OF CALIFORNIA• WATER RESOURCES CONTROL PARD :s` ms FORM `A': UNbkAGROUND STORAGE TANK PROGRAM SITE C—FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION } " . r COMPLETE THIS FORM FOR EACH FACILITY/SITE t C'<Lrr•OPNrP MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / 0 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) E Cn FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓So to tr4lcale ❑ PARTNEMLE ❑ STATE-AGENC p � El LOCAL AGENCY El RDn,pGENGY/c, 1 ❑ CDUNttAGENp�1 CITY NAME STATE ZIP CODE SITE PHONE M,WITH AREA CODE CA TYPE OF BUSINESS: 29wfl6urrm ❑/PROCESSOR -/Box if INDIAN EPA ID N RESERVATION or A of TANK'N ❑ i GAS STATION 3FARM [:] 5OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N 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 MAILING or STREET ADDRESS ✓Sox to intlicale ❑ PARTNERSHIP O STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-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 ❑ INDIVIDUAL ❑ 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYIN JURISDICTION N AGENCYN FACILITY ID N N of TANKS at SITE CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ,/?S = _3:x YES NO CHECKIF PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY:: `TZ3 THIS FORM BUST BE ACCOMPANIED BY AT LEAST(1)0 MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) • (�V1 \ •DATA PROCESSING COPY Q