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STATE OF CALIFORNI WATER RESOURCES CONTROQOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I a COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7_ffRMANIlNlLY=SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 00 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Gt/ cc I r/1. ha Ll� PTa er-fi,es ADDRESS NEAREST CROSS STREET ✓Boa b wiwle Cl PARTNERSHIP ❑ STATE AGENCY ,T / I' l /Y i „„ s�, ❑ CORPORATION ClLOCAL AGENCY 1-1FEOE L GENLY (/1 U / A [ u/�� '— ❑ INDIVIDUAL ❑ COUNIY-AGENCY CITY NAME i / STATE ZIP ODE SITE PHONE I WITH AREA CODE K CA 5 Cao9 07 TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box d INDIAN EPA ID a RESERE] ❑ TRUST YLANDS ATTHISSITEATION D ❑ i `� O 1 GAS STATION FARM 5 OTHER EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYSNAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST( PHONE N WITH AREA CODE (.;Lo 9 *(03-70 NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS %/Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY 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: I. ❑ 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 N AGENCY# FACILITY ID If #of TANKS at SITE 6 10 1 Z41 ��I ;, 0000 CURRENT LOCAL AGCY FACILITY Ip N APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION ODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS.PLAN FILED NO ❑ DATE FILED }� A3 I as CHECK 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) DATA PROCESSING COPY