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or r STATE OF CALIFORNIA-- WATER RESOURCES CONTRObWOARD FORM A : UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION < COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAMECARE OF ADDRESS INFORMATION J 5ervice- ADDRESS NEAREST CROSS STREET ✓BmwN D FABTNEIMP D STATE AGENCY m� D COMMTION D LOGL-AGBO D FEDEW AGENCY Cl INDMDIIAL D OJUNTY.AGENCY CITY NAME STATE ZIP CODE SITE PHONE If,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ A PROCESSOR R✓SERVATION dr AT THIS SITE Box if INDIAN EPA ID N N of TANK'# E ❑ ❑ t GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME ILAST,FIRST) PHONE N WITH AREA CODE 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 ADDRESS ✓Sox to indicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIPCODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to i,ftate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY Cl FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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. ❑ I. ❑ 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 LOCAL AGENCY USE ONLY COUNTY R JURISDICTION N �AGENCCYYII NFACILITY IDM N of TANKS 8t SITE 'uT"' 1--�—� CURRENT LOCAL AGENCY FACILITY IP N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NU R \ PERMR APPROVAL DATE PERMIT EKPIRATION DATE RE CENSUS TRACT SUPERVISOR-D18TIIICT CODE BU BIN ESS PLAN FILED DATE RILED O 32--5— YES ❑ NO 1�v PERMIT AMOUNT SURCHARGEE AMOUNT FEE CODE RECEIPT# 8Y: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `S'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL . JORM A(3-2-88) 3 -9 \ •�