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STATE OF CALIFORN4 WATER RESOURCES CONTROBOARD I i FORM `A': � � SITE UNDERGROUND STORAGE TANK PROGRAM FACILITY/SITE, TY/SITE, INFORMATION and/or PERMIT APPLICATION z i _ o COMPLETE THIS FORM FOR EACH FACILITY/SITE C'IIIVOP NIP c O MARK ONLY ❑ 1 NEW PERMIT E]3 RENEWAL PERMIT ONE ITEM ❑5 CHANGE OF INFORMATION 7 PERMANENTLY C i �2 INTERIM PERMIT � 4 AMENDED PERMIT CLOSED SITE 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE FACILITY/ ITE NAME COMPLETED) CA CARE OF ADDRESS INFORMATION ADDRESS NEAR EST CROSS STREET RA 10 irdirak ❑ PARTNERSHIP I -J FZ/ ❑ COPPORATION El LOCAL E LOCAL AGENCY DERALAGENCY CITU NAME ❑ INDIVIDUAL FI COUNTY AGENCY STATE ZIP CODE SITE PHONE N,WITH AREA CODE TYPE OF BUSINESS: Lj 2 DISTRIBUTOR 4 PROCESSOR ✓BOX if INDIAN EPA D NA ION or TRUST OS 1 GAS STATION 0 3 FARM 5 OTHER RESERVAT ❑ - #of TANK'# LA EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE DAYSNAME(LAST,FIRSTI EMERGENCY CONTACT PERSON(SECONDARY) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax m inftwe ❑ PARTNERSHIP ❑ STATE-AGENCY CITY NAME ❑ CORP DATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCYE3 INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE p,WITH AREA CODE 111. TANK'OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME JCARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box la'm4icata ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCYCITY NAME El INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE k,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. E if. E if. 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# H of TANKS at SITE 3 L5 CURRENT LOCAL AGENCY FACILITY IDNLSURCHARGEAMOUNT PPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# E BUSINESS PLAN FILED DATE FILED YES NO ❑CHECK# PERMIT AMOUNT FEE CODE RECEIPTM 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 NLY. q FORM A(3-2-88) 4 LAJ DATA PROCESSING COPY