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STATE OF CALIFORNIkr WATER RESOURCESCONTROr'SOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-11 NEW PERMIT F—] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 1 PER ENTLY CLOSED SITE I� ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE U/ m I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N FACILITY/SITE NAME K17 CARE OF ADDRESS INFORMATION ADDRESS /%) NEAREST CROSS STREET ✓3,m bikisk D PARMNEASAIP 0 STATEAGENCY ElINDCa�ALI� DO W�YCENCY D FEDERAL AGENCY CIN NAME STATE ZIPCODE / SIT ON=.WITH )E SIZGG CA SS C6 5� TYPE OF BUSINESS: ❑ p IBUTOR ❑ 4 PROCESSOR I ✓Wx if INDIAN EPA ID a It of TANK'F ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUSTMLANDS ATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NNAAME 166T.FIRST) n/� PHO 0 WITH CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME ILA IRST) f!/ PHONE#WITH AREA CCODDE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME ^� CARE OF ADDRESS INFORMATION MAILING or STREET AD SpNQ ✓Box to indicate D PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY 11 INDIVIDUAL D COUNTY-AGENCY CITU NAME STATE A ZIP CODE � � PHONE p, ITHAREA CODE III. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETED)/'LJ NAME C CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP 0 STATE-AGENCY D CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY D INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIPCODE PHONE#.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. N7 Ill.❑ 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# AGENCY II CILITY ID R N of TANKS BI SITE Ea )- q am D CURRENT LOCAL AGENCY F # APPROVED BY N PHONE#WITH AREA CODE C) tF PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIONCODE CENSUS TRACT SUPERVISOR-0113i CODE BUSINESS PLAN FILED DATE FILED YES NO CHECK# PERMIT AMOUNT SURCHARGE AM NT FEE CODE RECEIPTM BY ,/J / THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK Pi FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION FORM A(3-2-88) c, DATA PROCESSING COPY V �J