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STATE OF CALIFORNIA WATER RESOURCES CONTRO&ARD -�" FORM A : UNDERGROUND STORAGE TANK PROGRAM ? 9 3 SITE /- FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIO COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ / NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PEOMWEU4YCLOSeOSITE ONE ITEM [:] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE S 6 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Ynixi ADDRESSNEAREST CROSS STREET V8 ordFN, 0 FARTNER$HP 0 STATE AGENCY Cl CO MTION 0 Lara AGENCY 0 FMAL AGENCY L• �! 1 I -I ,� 0 INGMDUAL 0 COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE f�oG CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PSOCESSOR ✓Box if INDIAN EPA 10 N N of TANKa ❑ I GAS STATION ❑ 3 FAROOTHER TRUSTESERYLANDS ATION of ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME( FIRST) PHONE M WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST.FIRST( PHONE NWRH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to InoiCate Cl PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL Cl COUNTY-AGENCY CRY NAME STATE ZIP CODE PHONE#.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS \ ✓Box to m7icate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 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 WNICN ADOYB ADDRESS SHOULD BE USED FOR tlOTN LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANO,TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) \ DATE LOCAL AGENCY USE ONLY 57_1 3 COUNTY M JURISDICTION B AGENCY B B of TANKS N SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE a WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE =Iii ON DATE LCHCE ATIO COOE CENSUSTIIACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED D t�a YES NO If PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Y: THIS FORM MUST BE ACCOMPANIED BY AT LLjEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(,), UNLESS THIS IS A CHANGE OF SITE INFORMATIO\yJ'}ONLY. \Y.1 FORMA 13-2-88l�� 1 ] • ��"\�.. �l ♦ � Li,YP« �1� I