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STATE OF CALIFORNIA WATER RESOURCES CONTROI:GARD F Y A FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o El COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT FvRFCHANGE OF INFORMATION ❑ 7 PERM A T SED SITE I"A' ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE L53 N I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CSD FACILI (SITE NAME CARE OF ADDRESS INFORMATION itufur no ^ A-N'W14 ADDRENEAREST CROSS STREET ✓Em loirdeile ElPAIRNEASHIP 11 STATE AGENCY ��!!•• 11 Six ElLDCAL-AGENCY 11FEDEItALAGENCY ga ❑ INDWIDM ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS: ❑2DISTRIBUTOR ❑ d PROCESSOR -/Box if INDIAN EPA ID # RESERVATION or #of TANK's L] 1 GASSFATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N 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 ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. ❑ U.❑ 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# #of TANKS at SITE E= = = Idol ( 14- 41_4> 6 -0 -0 (0 CURRENT L CAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE _ cpac,35 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L DE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES � NO � � I 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. FORM A(3-2-88) go 0 "- DATA PROCESSING COPY