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STATE OF CALIFORNIA• WATER RESOURCES CONTROLOARD FORM 'A': ��; UNDERGROUND STORAGE TANK PROGRAM LAN SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE -ry, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT B CHANGE OF INFORMATION ❑ 7 PERMANENTLY SED SITE ti ONE ITEM ❑ 2INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/ E NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓3Nbxgpe ❑ PARINEFSIIP Cl 31A1-AGENCY 001P)UTION ❑ 10CALAGDO ❑ )EOE ,AGENCY ❑ NDYIOWI ❑ COUNTY AGENCY CITY NA STATE ZIP CODE SITE PHONE A.WITH AREA CODE G CA 3i-37. ? TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID a ❑ 7 GAS STATION ❑ 3 FARM - a OTHER RESERVATION or ❑ -THIS SITE Q EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) ENAELAIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE ��r. IRST) PHONE NITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATI N & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS '/Boa m meicale Cl PARTNERSHIP ClSTATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE III. TANK OWNER INFORMATION & ADDR S — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to mtlicale ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED OR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR ND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPUCANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY •COUNTY R JURISDICTION a AGENCY R FACILITY ID a a of TANKS at SITE CURRENT CAGE LOL AG FACILITY 10 0 APPROVEO BY NAME PHONE a WITH AREA CODE Con) 49 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA ION CODE CENSUS TRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE F LED OC YES NO C] CHECK, PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT F BY: THIS FORM MUST BE ACCOMPANIED BY ATC it MORE TANK PERMIT FORM '8'APPLICATION(S)• UNI ESS IS A CHANGE OF SITE INFORMATION ONL)'.^ F6PM A(3-2-88) �' I /4 r✓1 DATA PROCESSING COPY