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yc4 oT-h 1 STATE OF CALIFOR46mr WATER RESOURCES CON�ff6wBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) FACILITY/SITE N ME CARE OF ADDRESS INFORMATION �3 e c 1' ADDRESS NEAREST CROSS STREET ✓BaailaoN 0 PAAiNEnHIP 0 STATE AGENCY /332 /y 0 COWWTDN 0 LUCAL-AGENCY C FEDEMIAGENCY ❑ #OMDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE VV TYPE OF BUSINESS: ❑pN o1 TANK'# _,DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID # E] I GAS STATION 3 FARM 5 OTHER RESERVATION or❑ TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE O NIGHTS: NAME(LAST,FIR T) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER )NFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION _C� ti f/u/IJxtJ MAIUNGor STREETADDRESS ✓Boz to indicate D PARTNERSHIP 0 STATE-AGENCY �7�-, D CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY oAL� O D INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE g zo -7�2--- Ill. i111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY D INDIVIDUAL 0 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. ❑ it. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N #o/TANKS at SITE mI I I CURRENT LOC/A�L AGENCY FACILInnTY ID Y APPROVED BY NAME PHONE#WITH AREA CODE L o� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENS'�UTYSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3/ a� YES D NO ❑ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# S , 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. FORM A(3-2-SS) �" DATA PROCESSING COPY TA/