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STATE OF CALIFORNI9 WATER RESOURCES CONTROMIOARD FORM `A': a UNDERGROUND STORAGE TANK PROGRAM =mom ro" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE Fr ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE -4 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) �/ 1bk FACILITY/SITE NAME CARE OF ADDRESS INFORMATION w r ADDRESS NEAREST CROSS STREET ✓Rov to inOiCBle ❑ PARTNERSHIP ❑ STATE AGENCY —1l 0 n r� F ❑ I IJ ORPORATITION 13 LOCNryAGENC! ❑ FEDER4LAGENW CITY NA14f� AGENCY A STATE ZIP CODE SITE PHONE k,WITH AREA CODE CA TYPE OF BUSINESS UISTRIBUTOR 4 PROCESSOR ✓ ❑ Box if INDIAN EPA ID p ❑ I GAS STATION ❑ 3 FARM ❑5 OTHER HSERVLANDS or ❑ X of TANK's LIST 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(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p 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 El ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY(-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 11 STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY El INDIVIDUAL. ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. ❑ 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 R AGENCY R FACILITY ID M a o1 TANKS at SITE 6 10 11 d 4 S I ol nl ol O CURRENT LOCAL AGENCY FACILITY ID A 1 1 Z ^ C L4_� l APPROVED BY NAME PHONE M WITH AREA CODE EPERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Qt/C{iQE CEN8U8 TRACT 1 _ SUPERVISOR-DISTRICT CODE BUSINESS PLAN❑FILED NG ❑ DA[E FlL,ED f _ \ CHECK# l.•il PERMITAAIM)`OUNT�)v\ SURCHARGE AMM\OOUNT FEE CODE RECEIPT# I IBBYY: \C/ 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