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STATE OF CALIFORNID WATER RESOURCES CONTASOARD FORM `A': PROGRAM A; o UNDERGROUND STORAGE TANK f FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION SITE ilcpRN C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-1I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El7 PERMANENTLY CLO_SiEED :. ONE ITEM El 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE 7t 11 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ------------------- ADDRESS NEAREST CROSS STREET I ❑✓CARP0RA7ON Cl �OOGNtHbIlIF L AGENC'f Cl FENRAL-AGENCY i� ❑ INDIVIDUAL ❑ CMNTY.AGENCf STATE ZIP CODE SITE PHONE a.WITH AREA CODE CITY NAME r; CA CA < 33u TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA 10 x Rot TANK'>< RESERVATION or ElAT THIS SITE ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS 1. EMERGENCY CONTACT PERSON(PRIMARY) I EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS ✓Box to Indlcale ❑ PARTNERSHIP ElSTATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE a,WITH AREA CODE CITY NAME I11. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ClSTATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY STATE ZIP CODE PHONE 4,WITH AREA CODE CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADOREES 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. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY R FACILITY ID M N of TANKS at SITE 3I 9 � C� EI CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ig LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED :NO a CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODERECEIPT N THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B',APIPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY FORMA(3-2-8lKE8) � 1 �� t 3 ��