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2. STATE OF CALIFORNIAO WATER RESOURCES CONTROLB ARD FORM A: UNDERGROUND STORAGE TANK PROGRAM �o Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE ONE IT ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) (co FACILITY/SITE NAME ` " CARE OF ADDRESS INFORMATION G-tv�h 6 7iN�, ADDRESS NEAREST CROSS STREET vdorw Cl PARTNERSHIP O STATE AGENCY I {� )f 0 I`u- I j� 11 COAPGNAnON ❑ LOCAL AGENCY ❑ 001A.AGENCY V V V ((7 IM (\{.( INOIVIOUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP COPE SITE PHONE#,WITH AREA CODE M CA S -0 TYPE OF BUSINESS: ❑ ISTRIBUiOR ❑ 4 PROCESSOR ✓Sox if INDIAN EPA ID # #of TANK's ❑ 1 GASSTATION 3 FARM ❑ 5 OTHER RESERVATION RUSTLANDS or 1:1 ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME R / /A / D CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Don to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY [, '/ �/ V ✓ ` ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE o C� S III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION - MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. 1 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE CURRENT LOC ;TNJ;Y FR�I�D# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER 'r/J1, +V, O"�`PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED / �2 6) YES � NO El �—/ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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.i FORM A(3-2-88) . 7 DATA PROCESSING COPY