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STATE OF CALIFORNIA WATER RESOURCES CONTRO(40ARD ,; "F FORM 'A': UNDERGROUND STORAGE TANK PROGRAM U SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C COMPLETE THIS FORM FOR EACH FACILITY/SITE o , MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT HANGS OF INFORMATION ❑ 7 PERMANENTLY CLOSEDSITE j ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 7 i 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) l o FACILITY/SITE NAMECARE OF ADDRESS INFORMATION N ADDRESS NEAREST CR"L5 Nicals ❑ PARTNERSHIP ❑ STAR All 3 C� RATION ❑ IOC AGEN ❑ FEDERAL AGENCY 1 cJ ClWAL ENC! CITY NAME STATESITE PHONE N.WITH AREA CODE 4 CA I TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR '/Box A INDIAN EPA ID N ❑ 1 GAS STATION ❑ 3 FARM ffA TRUSTYLANDS ATION or ❑ ,� ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) III DAYS' NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME ST,FIRST)) PHONE N WITH AREA CODE Z// �nv 409 NIGHTS'. NAME(LAST, IRST NE N WITH AREA CODE NIGHTS: NAME(LA,6T,FIRST) PHOII N WITH AREA CODE i II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAM CARE OF ADDRESS INFORMATION � Y ✓ =� J II MAILING or STREET ADDRESS ✓Box to indicate U ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑� LO��.ppL-AGENCY ❑ FEDERAL-AGENCY P. ❑ INDIVIDUAL LYQOUNTY-AGENCY CITY NAME STAT ZIP CODE PHONE p WITH AREA CODE 157402- 3 -moi III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME �. CARE OF ADDRESS INFORMATION zs LP MAILING or STREET ADDRESS ✓Box to intlicate ❑ 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. EIK 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY Lt JURISDICTION k AGENCY R FACILITY ID B B of TANKS N SITE CURRENT LO A NCY/FACILIT'ID V APPROVED BY NAME PHONE K WITH AREA CODE L PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT If SUPERVISOR STRICT CODE BUSINESS PUN FILED DATE FILE a71 YES NO CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN I toy: 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. FORM A(3-2-88) �. rI / l DATA PROCESSING COPY 7w