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gz' O* TM1 STATE OF CALIFORNIA WATER RESOURCES CONTRA ARD AA FORM AA': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FA LITY/SITE `'<�soar•`r MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYD SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 53 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CRABS STREET ✓Rmbid'rab ❑ PARTNERSHIP ❑ STATEAGENGY i+ A ❑ CGWORITION ❑ LOCAL-AGENCY ❑ AGENY ❑ INGMDUPL ❑ COINTYAGENCY CITY NAME STATE ZIP CODE S TE PHO E p,WITH AREA C��a CCA eT'CJ 3(/P TYPE OF BUSINESS: 2 DWRIBUTCA SSOR ✓Box R INDIAN EPA ID N /v v Y X of TANK'S ESE ❑ i GAS STATION ❑3 FARM TRUSTYATION LANDS or ❑ AT THIS SITE 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 ao - 33a NIGHTS: E(LA ,FIRST) qq HONE N ATH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE OV 11. PROPE6ii OWNE INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME o CARE OF ADDRESS INFORMATION MAILING or sTAEV ADDRESS ✓Boz 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 MAILING or STREEfADDRESS ✓Box toindicete ❑ 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 LEM NOTIFICATION AND BILLING: I. ❑ if. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY R FACILITY IDR N of TANKS Bt SITE U& la 15qCURRENT LOCAL AOE CY FACILITY IDN APPROVED BY NAME PRONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED �T 3 YES NO CXECKN PERMIT AMOUNT SURCNMOE AMOUNT FEE CODE RECEIPTN Y: 111 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. �� JORM A(3-2-88) 0