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STATE OF CALIFORNIAN WATER RESOURCES CONTROL(ARD FORM 'A': UNDERGROUND STORAGE TAN ROGRAM Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; Io (/ COMPLETE THIS FORM FOR EACH ACILITY/SITE °�""•' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E!f5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F'a ONE ITEM E] 2 INTERIM PERMIT E]4 AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE 1 00 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) OD FACILITYkSITE NAME ` CARE OF ADDRESS INFORMATION TAr'rtfr C'4-6f 2g ADDRESS NEAREST CROSS STREET ✓Bwlo mtinle ❑ FARINERa'4IF ❑ STATE AGENCY ❑ iION ❑ LOCAL AGDO ❑ FEDERAL AGENCY le" f �� INOMOUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE It.WITH AREA CODE CA W3_5_000 TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a N of TANK'F ESE ❑ 1 GASSIATION ❑ 3 FARM ❑ 5 OTHER TRUSTVATION LANDS or E]LANDS 4v01 S'9 381 AT THIS SITE O EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS Be.✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. ❑ 11. ❑ If.❑ 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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE m CURRENT LOCAL AGENCY FACILITY ID Al APPROVED BY NAME PHONE N WITH AREA CODE EL 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED YES � NO ❑ CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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. FORMA(3-2-88) -- a �� DATA PROCESSING COPY L-.d5