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m STATE OF CALIFORNIf WATER RESOURCES CONTROL OARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION nA COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ f NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E17 PERMANENTLY CLOSED SITE Z ONE ITEM ❑ 2INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE •Q I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADD $S N NEAREST CROSS STREET ✓B0 0 PAFNEFIIF 103STATE-AGENCY V� t&Lew Ocdcls NPOAATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY 13INDIVIDUAL C3COUNIYAGENW tt NAME STATE ZSITE PHONE H.WITH AREA CODE CA 5J�3d U TYPE OF BUSINESS: p DISTRIBUTOR 4 PROCESSOR ✓Boxif INDIAN EPA ID H 1 GAS STATION ARM 5 OTHER TRUST LA I OS ON or ❑ F of TANK's AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE H WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE H WITH AREA CODE 11-916EF NIGHTS: NAME(LAST, RST) 1, 7 PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE H WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME 019-116 6 /J _ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS R✓ indicate 13 PARTNERSHIP ❑ STATE AGENCY ORPORATION O LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY NAME STATE ZIP CODE PHONE H,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) J NAME —_ CARE OF ADDRESS INFORMATION rI MAILING or STREET ADDRESS ✓Dox tc,ftcate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE H.WITH AREA---- 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION N AGENCY N F 1 M Of TANKS at SITE O �_ F CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME PHONE N WITH AREA CODE 1 GG O PERMIT NUMBER I I PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DIS/TRIICCT CODE BUSINESS PLAN FILED E ATE FILED Zlo YES ❑ NO -SqONLY. CHECKM PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM 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 INFO r�Fo\A(ss)�� • DATA PROCESSING COPY