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STATE OF CALIFORNI10 WATER RESOURCES CONTRJAOARD { f FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION c a COMPLETE THIS FORM FOR EACH FACILITY/SITE ""°°�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA TLV CLOSED SITE w ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1531 I— IV 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 00 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION /7u1zAC� lK2 �T NEAREST CROSS STREET Su 10 Not -A EA GEICI El CORMPALIBN LOCAL AGENCY ❑ FEDERAL AGENCY_"774_6w, ❑ INDIVIDUAL ❑ COUNIYAGCNCY CITU NAME STATE ZIP CODE y/,. J SITE PHONE N,WITH AREA CODE IMul TYPE OF BUSINESS 2 DISTRIBUTOR �� 4 CESSOR ✓Box if INDIAN EPA IDN 9 S YJ At of TANK's ❑ ,u/ RESERVATION or �.,,_ e F-11 GASSTATIDN F-13 FARM 5 OTHER rI TRUST LANDS ❑ V a Y� AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAS F � IRST) � PHONE k WITH A CODE DAYS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE ug NIGHTS: NAME(LAST IRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMES ^ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ 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 S 1 MAILING or STREET ADDRESS I/Box to lntlicate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY 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. if. ❑ 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 M JURISDICTION N AGENCY M FACILITY IDM M of TANKS at SITE CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE Al WITH AREA CODE 7R� --7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION-CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS S NFRED NO ❑ DATED L/3 CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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.5FORMA(3-2-88) ! DATA PROCESSING COPY 0