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STATE OF C.ALIFORNFpr WATER RESOURCES CONTROrl3OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM S FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z to COMPLETE THIS FORM FOR EACH FACILITY/SITE ¢o MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY ED SITE I" ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE - I_& I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) CD FACILITY/SITE NAME CARE OF ADDRESS INFORMATION AD)Wr& NEAREST CROSS STREET ✓Sa bikiule 0 PAWREMIP 0 STATE AGEN ❑ CGRPOAATIM ❑ LOCAL-AGENCY 11 FEDERALAGI 11INDMDUAL 0 COUn AGENC/ CITY NAME ` STATE ZIP E SITE PHONE N.WITH AREA CODE V CA TYPE OF BUSINESS: ❑ 2 DI ISUFOR ❑4 PROCESSOR ✓Box,f INDIAN EPA ID a p of TANK'p F—] 1 GAS STATION FARM E: 5 OTHER TRUST LANDS ATION o ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE a ,;j;H NAME(LAST,FIRST) PHcfF4E a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME / CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓80x to intlicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE A III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP 0 STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a.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: 1. it. ❑ 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# JURISDICTION p AGENCY p FACILITY ID p p of TANKS at SITE m 010 in 10 CURRENT LOCAL AGENCY FACILITY N n T 'J^(/'n -` APPROVED BT NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL IIIDDAATTE PERMIT EXPIRATION DATE LOCA OfL70DE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED / a3 1 A� YES NO CHECK p 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 ONLY. FORM A(3-2-8&) DATA PROCESSING COPY