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STATE OF CALIFORNIA) WATER RESOURCES CONTROL'496ARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION & COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFFORRMAT IO ` ADDRESS NEAREST CROSS STREET Box Al, D PARTNERSHIP D STATE AGENCY 00N JJ RPGRATION 0 LOCAL-AGENCY 0 FEDERAL AGENCY ��AI /OV D INDIVIDUAL D COUNTY-AGENCY 'V, CITY NAME STATE ZIP CODE SIT HONE#,WITH AREA CODE CA TYPE Of 6USINESS. ❑ p DISTRIBUTOR PflOCESSOR -/Box if INDIAN EPA ID # If of TANK's ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSRESETYATION ANDS o ❑ �K AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(ATIST IRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST.FIR PHONE p WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME �-, CARE OF ADDRESS INFORMATION MAILINNGL/(o',,STBE` TT`A(DiDCR,Er(9, ✓ lointlicale 0 PARTNERSHIP ❑ STATE-AGENCY /J CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY j�� Q 0 INDIVIDUAL ❑ COUNTY-AGENCY cITY N E - STATE ZIP CODE zo #WITH cODE �� Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) O NAME CARE OF ADDRESS INFORMATION MAILINGor STREET ADDRESS -V8 Indicate 0 PARTNERSHIP 0 STATE-AGENCY /' ORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY )0 {� / D INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE IV. LEGAL NOTIFIC TION AND BILLING ADDRESS � CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. El II. If EO] 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# FACILITY ID# #of TANKS at SITE EE [� DO / o6 CURRENT LO*L AGENCY FACILITY ID k APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PEI EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR- (STRICT CODE BUSINESS PLAN FILED DATE FILED YES NO ^.23 CHECK* PERMIT AMOUNT SURC I 1EAMOUNT 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 swops, s