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. .17T a ,ti....-..r .aaar ,v+s-.Te�m'.�T""'.r"..a`"Tr '.''"'-T'r".z9'"°........_. ..;r-'^.... :.".{„^TP: # T�F.r,.._.,-.---wr.-..�. STATE OF CALIFOR WATER RESOURCES CONTIN BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM = ” o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ;! 10 zq COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 1pr5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F-a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 63 00 I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) A' CTI FACILITY/SIT AME CARE OF ADDRESS INFORMATION �J/✓Il S ADO��`* RE NEAREST CROSS STREET I/8m to irx le REAS TNHIP ❑ STATE AGENCY ' ❑ INDIVDUALION � COUNW AGENCY ❑ ROEAA AGENCY VEOCITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA p; TYPE OF BUSINE S: ❑ 2 STRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID it ❑ ❑ RESERVATION o ❑ #of TANK'. / I GAS STATION 3 FARM 5 OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(I-AST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME(\ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAM CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ 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. ❑ 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 R JURISDICTION N AGENCY N FACILITY ID K k of TANKS at SITE CURRENT OCALVLYC) AG Y FF_A)CILITY{]# APPROVED BY NAME PHONE N WITH AREA CODE J tx PERMIT NUMBER PERMIT APPROVAL DATELCODE PERMIT EXPIRATION DATE LOC N�/ODE CENSUS TRACT# SUPERVISOR-DDIISTTRRIBUSINESS PLANFILED DAATE F E-1O (�7 YYES NO EI ( �17/OCHECKN PERMIT AMOUNT SURCHARGE AMOUNODE RECEIPT# BY. A I 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. \71LlVII FORMA(3-2-SR) DATA PROCESSING COPY 0