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STATE OF CALIFORNO WATER RESOURCES CONTRO BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM ~`~ �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE I"J ONE ITEM F-12 INTERIM PERMIT ❑4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE v N 00 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) -4 ILI FAC /SITE NAME CARE OF ADDRESS INFORMATION 0 r �- r ��, an 0 t-k_)CeYcj t (11 Co�c�rl ADDRESS N REST CROSS STREET ✓ N 0 PARTNERSHIP 0 STATEAGENCY 31 M �kmtlAaTION l� �, 1a1 � y � FS ❑ LOUNTYA E ❑ fEOEPALAGENC I. 1.I�2. C)r- mouAt ❑ cou#ry ncENcr CITY AME STATE CODE SITE PHONE a,WITH AREA CODE CA S.)Ll o 20 3 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box it INDIAN EPA ID # ❑ 1 GASSTATION ❑ 3 FARM E] 5 OTHER it LANDS or ❑ �— AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. N M (LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE (J NIGHTS; PAVE(LAST,FIRST) PHONE#WITH AREA COD NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE N r Jd36 3& II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME I CARE OF ADDRESS ANFERMAi19FF—_-- Maj MAILINGorSTREEI ADD SS %/Box to indicate 1-1PARTNERSHIP11 STATE-AGENCY Q. ❑ C9RPORATION ClLOCAL-AGENCY 0 FEDERALAGENCY INDIVIDUAL 0 COUNTY-AGENCY CITY NAME ST ZIP�ODE �`� PHONE#,WITH AREA CODE J p�� 7 l III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME ^ CARE OF ADDRESS INFORMATION ' /u MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE AGENCY ❑ CORPORATION 0 LOCALAGENCY ❑ FEDERALAGENCY ❑ 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. ❑ 11—inIII. ❑ 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 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE i 3R I eDl = d Rl CURRENT LOCAL AGENCY F CILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE Sona PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D TE FILED r LJ I YES NO ❑ `3 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 FORMA(3-2-00) DATA PROCESSING COPY