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�_ • s STATE OF CALIFORMY WATER RESOURCES CONTRO OARD ° FORM 'A,. UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ¢- '` COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT '(-s CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS / NEAREST CROSS STREET +/3.1.i .* ❑ PMAT OKW ❑ STATE-AGDO i— ❑ Cf)APOA PON ❑ IAG4-AGENCi 13B�A4AG FEDM �! C]%�1 /t1 G7C t r/G- ❑ OMWAL ❑ a M AGENC! CITY NAME 57 STATE ZIP CODE SITE PHONE 0.WITH AREA CODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑dR RE, x 4 INDIAN ON EPA 10 M If of TANK i ❑ 1 GAS STATION ❑ 3 FARM S OTHER TRU5T LANDS AT THIS SITE O EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE 0 WITH AREA CODE C NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE r 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE'OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/Box Io indicate ❑ PARTNERSHIP ❑ STATE-AGENCY i - ❑ CORPORATION' ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 0,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET AODRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY - CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY 4 CITY NAME - STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDREN SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II, ❑ NL❑ 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 M AGENCY M FACILITY ID! N of TANKS at SITE 3 0 0 1 / 3 3 o c� d CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE V6AAJ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIONIC ODE CENSUS TRACT SUPERVISO"ttBTRiCT CODE SUSiNESS PLAN FILED DATE FILED d 3 .�O2 I YES El NO C CHECK Y PERMIT AMOUNT SURCHARGE AMOUNT T�_cDOE RECEIPT A BY: 3/'o THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICAT€ON(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-68)