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STATE OF CALIFORNIP WATER RESOURCES CONTRO•OARD \ A f ' �u•x1 A FORM A: UNDERGROUND STORAGE TANK PROGRAM u �o SITE ! O FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° , 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA CLOS E I-a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE b W I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CD 00 FACILITY/ TE NAME y �� CARE OFA DRESS INFORMATION ADDRESS ! /�1t NEAREST CROSS STREET Box to TIO ❑ LOCAL GEN ❑ STATEAGENCY lJ ❑ CORPORATION ❑ IOCAt AGENCY FEDEPAIA ENLY Cl INDMDUAL 0 COUNTYAGENCY CITY NAME � STATE ZIP S SITE P ONE#,WITH AREA CODE o�t CA TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N GAS STATION ❑ 3 FARM ❑ S OTHER TRUSESETMLANDS ATIONo ❑ � #of TANK'e AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAyC: NAME(/LAwS.T,FIRST) V•V'�/�-/ PHONE If WITH AREA CODE DAYS. NAM y(LAST,FIRST) PHONE It WITH AREA CODE Y •V ✓V� NIGHTME(LAST,FIRSPI") PHONE CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE 14 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) ('(/({//�I/ NAMFL) CARE OF DDRESS INFORMATION N MAILING Dr STREET ADDRESS ✓box to Indicate Cl PARTNERSHIP 0 STATE-AGENCY `Lo6tx ❑ CORPORATION ❑ LOCAL-AGENCY a FEDERA AGE Cy ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NA STATE ZIP CODE PHONE#,WITH AREA CODE S �W'V Y— III. TANK OWNER &FORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL O COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE#.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. Fr III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAMEPRINTED SIGNATURE)( t S G A UAE) BATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION Al AGENCY# FACILITY ID If If of TANKS at SITE = a l On I o CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY AM PHONE WITH AREA CODE Gym PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DA LOCATION CODE CENSUS TRACT#� SUPERVISOR-DIST ICT CODE BUSINESS PUN FILED DATE FILED S ❑ NO YES L J CHE # PERMITAMOUNT 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 01(LY: FORM A(3-2-88) • J DATA PROCESSING COPY