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STATE OF CiALIFORNhq WATER RESOURCES CONTR&BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM ;" mi SITE FA ILITY/SITE, INFORMATION and/or PERMIT APPLICATION m : o �I f COMPLETE THIS FORM FOR EACH FACILITY/SITE `'�'•on9`" MARK ONLY In 1 N'� 'PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PER / OSED SITE ONE ITEM - cRIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �l N I. FACILITY/SIT MATION & ADDRESS — (MUST BE COMPLETED) W C77 FACILITY/SITENAMEP2iL 72 CARE OF ADDRESS INFORMATION - SN�JuS1 ADDRESS NEAREST CROSS STREET /Swat O PAAINERSHIP ❑ STATE AGENCY T ❑ NDMEXAAI ❑ L�TYAG IN [IIDEM-AGE# CY CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE ZA CA It TAN TYPE OF BUSINESS: F-12 DISTRIBUTOR ❑4 PROCESSOR ✓eo%if INDIAN EPA ID p ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTVLANDS OT ElTTHII SI EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,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 Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS I/Box 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. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION II AGENCY# FACILITY IDN N of TANKS at SITE m ol 0 1 D CURRENT LOCAL AG ILL IDN APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMaR PERMIT APPROVAL DA PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUI-ERV)INOR-DISTIRpt CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 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< �-k,\10RM A(3-2-88) \l DATA PROCESSING COPY ,