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+ir t F STATE OF CALIFORNO WATER RESOURCES CONTRSOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM - AIL SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION .1 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) O FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS p NEAREST CROSS STREET ✓Bmtoiwiole El PARTNERSHIP 11STATEAGENCY ry D7o 5, Tern I ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY rs El INDIVIDUAL ElCOUNiRAGENCY CITU NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE N CA 9 2 3 � TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID a ESE❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVATION LANDSor ❑ It of TANK' a 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 it WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE It 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 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY'-AGENCY CITY NAME STATE 21P CODE PHONE q,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. ❑ it. ❑ 111.❑ 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) PATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION M AGENCYN, FACILITY ID R N of TANKS at SITE I 1 12- 2 O CURRENT LOCAL AGENCY ACILI IDM APPROVED BY NAME PHONE k WITH AREA CODE Z PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# CENSUS TRACcT M� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED / 2 , ) Z YES NO ❑ O PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION FORM A(3-2-88) n `��j �� DATA PROCESSING COPY