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STATE OF CALIFORNYA WATERy`lA:��ir •'. RESOURCES CONTROL BOARD t. •. lI FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION V � I COMPLETE THIS FORM FOR;EACH FACILITY/BETE � °'�iranH+P I ' 1� MARK ONLY F-11 NEIN PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE Af ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE •C I I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) cc FACILITYISITE NAME CARE OF ADDRESS INFORMATION NEAR CRO SET ✓qaq 1:1PAATHMIP ClSTATE-AGi;O ADDRESS L.� ❑ (XMi aMT)M ❑ LOC&AGDa ❑ FEDERAL-AGENCY Cl RIGIPIOIIAL ❑ CGIINTYAGDO ! CITY NAME STATE - ZIP CODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ a PROCESWR ✓8ox if INDIAN EPA ID # N of TANK t ❑ 1 GASSTATION [:]3 FARM ❑5 OTHER TRUST LANDS SEATION�I ❑ ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE - NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA-CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE ! 11, PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION i i i MAILING or STREET ADDRESS ✓Box 10 indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl MDIViOUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE it.WITH AREA CODE - J Ill. TANK OWNER INFORMATION &ADDRESS--(MUST BE COMPLETED) ' i NAME CARE OF ADDRESS INFORMATION . k i II MAILING or STREET ADDRESS ✓Box 10 indicate ❑ PARTNERSHIP ❑ STATE-AGENCY I ❑ CORPORATION [],LOCAL-AGENCY ❑ FEDERAL-AGENCY .,❑ INDIVIDUAL ❑.COUNTY-AGENCY I 1 CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE I IV. LEGAL NOTIFICATION AND BILLING ADDRESS i f CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ It. ❑ III-❑ i THIS FOAM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. I - I APPLfCANTS NAME(PRINTED&SIGNATURE) PATE 'i I i LOCAL AGENCY USE ONLY I j COUNTY# JURISDICTION# AGENCY* FACILITY ID# #of TANKS et SITE 1 FT I / I / lik ] 1 . 1 1 - 1 / 1 CURRE�QCAL AGENCY FACILITY IC a APPROVED BY NAME PHONE 11 WITH AREA CODE I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT m SUPERVISOR-OISTR=CODE BUSINESS PLAN nLED DATE FILED YES NO i i CHECK N' PERMIT AMOUNT SURCHARGE AMOUNT - FEE CODE RECEIPT# - BY: p i .k 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 Oh i FORM A(3.2.88) - i � - DATA PROCESSING COPY + ,. q