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STATE OF CALIFORNIS WATER RESOURCES CONTROL'EOARD :zc°" . FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o COMPLETE THIS FORM FOR EACH FA LITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I'+ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE P-A. I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) A FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS //��//�� A /� NEAREST CROSS STREET ✓Mor biat., 0 PARTNERSHIP 0 STATEAGENCY /!/f� �M/Id,/iy y- �O ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY V VV ,,/ Z �cL/ FiI ❑ NiI ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE Aw7e6�1 CAs 33sv 2a /�V TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR F-14 PROCESSOR ✓Boz it INDIAN EPA IDRESEp TRUSTATION LANDS or ❑ AT HIS SITE / ❑ 1 GAS STATION ❑ 3 FARM OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME fLAST.FIRST) tV FrIONE 4 WITH AREA CODE NIGHTS'. NAME(LAST FIRST) PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME ` CARE OF ADDRESS INFORMATION J MAILING or STREET AD RESS ✓Box toind,cate 0 PARTNERSHIP 0 STATEAGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET A DRESS %/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,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 R JURISDICTION k AGENCY S FACILITY ID R N of TANKS at SITE EE I I I i s 10 CURRENT LOCAL AGENCY FACILITY ID k/) APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DI3T111CT CODE BUSINESS PLAN FILED DATE FILED�y � YES [:] NO CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a 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 ONL FORMA(3-2-88) DATA PROCESSING COPY 0 A