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TATE OF CALIFORNIA WATER RESOURCE LB T� S S CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM a _ o Z SITE C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION a o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EY-1 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) fes.► FACS/SITE NAME CARE OF DDRESS INFORMATION J e� r I Ls� ADDRESS NEARS TCROSS STREET ✓fkOrmixat ❑ PARTNERSHIP ❑ STATE AGENCY ❑ COAPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHO E k ITH AREA CODE CA gSZDS' 7if TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR F-1 4 PROCESSOR -/Box If INDIAN EPA ID a RESERVATION or X 01 TANICa /� ❑ I GAS STATION [:] 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE V EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DA NAME(LAST FIRST) PHO E X WITH AREA CODE DAYS' AVE(LAST,FIRST) P ONE If WITH AREA CODE �., 12r2wk t Zoy 7 z� o d 3 S S A NIG TS: NAME(LAST,FIRSTV PHONE N WITH AREA CODE NIGHTS NAME(LAST,FIRST) HONE X WITH AREA CODE 5 14 a 441_ 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME I CARE OF ADDRESS INFORMATION MAILING or STREET ADDRES ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME �--�V \ STAT ZIP ODE ZO I PHONE X,WITH AREA CODE IS+ 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 X,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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION X AGENCY X FACILITY ID X X of TANKS at SITE 3 = = 1010 1 I= 101 ol old CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE X WITH AREA CODE F PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE C LOCATION CODE CENSUSTRACTX SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILED O 1 a YES NO 79 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: JJ 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. ryORM A(3-2-88) �. 4 � DATA PROCESSING COPY