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STATE OF CALIFORNIN WATER RESOURCES CONTRIPBOARD 5E#� MF FORM A: UNDERGROUND STORAGE TANK PROGRAM Z SITE ,S:,, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m.l 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE 'IFOP"'� MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE W CD I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) w Na. CARE ADDRESS INFORMATION yr -F Si rn ADDRESS c (L NEAREST CROSS STREET ✓ wl Q 0 PON 11 ::E 0 STATE AGNCY I I INDIIVIDUALI� 0 WATYA-AGENCY ❑ RL'ERAL-AGBiGY 0 CITY NAME STATEtCODF q� SITE PHONE#.WITH AREA TYPE OF BUSINESS: ❑p DIMIBUTOR 4 PROCESSOR '/Box if INDIAN EPA ID # B of TANK s ❑ 1 GAS STATION [:] 3 FARM ��R TRUSTYLANDS or ❑ --�- AT THIS SITED EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NA E �T (LAST,FIIRRST'11 PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE (Y`e 1 9911 ')Cl NIGHTS: NAME(LAST,FIRST) P ONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILIN STREET SS� /� rJ�✓Bgto indicate ❑ PARTNERSHIP 0 STATE-AGENCY `-�11 _' RPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME C STAT ZIPCODE PHONE q,WITH AREA sCIYlq 03 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME nn CARE OF ADDRESS INFORMATION Cv MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY Cl CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOR INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it.. 2rIII.❑ 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# AGENCY# FACILITY ID# #of TANKS at SITE U 1 a -1 DO O CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION DE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ) D10 u c YES ❑ NO ❑ - J{ ( LG) 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 FORMA(3-2-88) J DATA PROCESSING COPY 0