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ALIF I STATE OFC RN O FORM `A'• WATER RESOURCES R ONTR ARD CSC O UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT El 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) ❑ 7 PERMANENTLY CLOSED SITE I FACILITY/SITE NAME CARE6 ADDRESS INFORMATION CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS co # ❑ STATE -AGENCY NoNkF- Y�✓ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ADDRESS ❑ INDIVIDUAL ❑ COUNTY -AGENCY NEAREST CROSS STREET ✓ §pr4mdicate ❑ PARTNERSHIP ❑ STATE -AGENCY STATE ZIP CODE PHONE #, WITH AREA CODE CORPORATION El LOCAL -AGENCY ElFEDERAL-AGENCY C� 1 9602 ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE SITE PHONE #, WITH AREA CODE CA Z�o_�L TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESS7RESBE'RVATION x if INDIAN EPA ID # # of TANK's C GAS STATION ❑ 3 FARM E]5 OTHERTRUST or LANDS ❑ AT THIS SITE 05— SEMERGENCY EMERGENCYCONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE :T2ZA„ '-?!25 y3 - r S,+A4C— NIGHTS: NAME (LAST, FIRST) PHONE# WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE po II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE6 ADDRESS INFORMATION ©P&O MAILING or STREET ADDRESS Boyx to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY �--- r• Y�✓ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE G©s C� 1 9602 III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ©P&O -� MAILING or STREET ADDRESS x to indicate 11PARTNERSHIP ❑ STATE -AGENCY 'poLr7 �✓ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE P11ONE #, WITH AREA CODE CENSUSS TR��A``,,C��--T��# lel✓47YES❑ SUPE�RjVI�SOR-DISTRICT CODE BUSINESS PLAN FILED NO❑/PERMIT /zz 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 8 SIGNATURE) DATE I noel OrFNCY 11SF nNLY 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. FORMA (3-2-88) 10 DATA PROCESSING COPY 0 N 004 JURISDICTION # AGENCY# FACILITY ID # # of TANKS at SITE AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE F PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUSS TR��A``,,C��--T��# lel✓47YES❑ SUPE�RjVI�SOR-DISTRICT CODE BUSINESS PLAN FILED NO❑/PERMIT DATE FILEED,3, 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. FORMA (3-2-88) 10 DATA PROCESSING COPY 0 N 004