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/54I'iu.�ei l�f OF STATE OF CALIFORNIV WATER RESOURCES CONTRIAGOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM =" n Z SITE ; FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION cgL,fo�,p 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 5 U-1 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 0) FACtUnE CARE OF ADDRESS INFORMATION L ADDRtE OSS STREET ✓ODWORATIO ❑ LOCPARTAL Cl FEATE DERAL AGENCY u C CAAPOAAL ❑ LOCAL AGENp ❑ fEGEAAL AGENCY ❑ INpNIpUAt ❑ CWNTI�AGENCYCITY ' ^ 21P DE SITE PHONE k,WITH AREA CODE Wd I ��5 �TYPE ❑ 4 PROCESSOR ✓Box if INDIAN N of TANK's 5OTHER RESERVATION or ❑ AT THIS SITE ❑ 1 GAS STATION ❑ 3 FARM ❑ TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS' NAME(I-AST,FIRST) PHONE N WITH AREA CODE DAYS: NIGHTS: NAM LAST.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME /,-\ CARE OF ADDRESS INFORMATION YYJ , C ) lX CSP 1 1I MAILING or STREET A ESS^ - %/Box indicate ❑ PARTNERSHIP ElSTATE-AGENCY [I CORPORATION ❑ LOCAL-AGENCY I] FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY AGENCY N,WITH AREA CODE l STATE„ IP ZCODEI CIN NAME /x '"(1 Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME T{— GENCY MAILING or STREET ADDRESS ✓Box to i RATIle ❑ PARTNERSHIP Cl STATEFEDERAL-AGENCY❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE p,WITH AREA CODE CIN NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. IL ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. UnrE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# AGENCY M FACILITY ID Al #of TANKS wattl SITE ® O U CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME PHONE N WITH AREA CODE N PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUS TRACTM SUPERVISOR-DISTRI CODE BUSINESS FILED LOCATI�� PLAN FILED DATE 1:1 YES El NO r CNECKM PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: as ;THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1) MORE TANK PERMIT FORM 'B'APPLICATION(S), US THIS IS A CHANGE OF SITE INFORMATION ONJ M A(3-2-8B) DATA PROCESSING COPY