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STATE OF CALIFORNI.0 WATER RESOURCES CONTROIROARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAMr SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONIw 70( ° ; o COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 v 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CD FACILITY/SITE NAME CARE OF ADDRESS INFORMATION /R 5 IDO ADDRESS /�/� .�+ NEAREST CROSS STREET ✓BoaoiWale D PARTNERSHIP D STATE AGENCY Cl7 65 S. //A1/U1� 2 ❑ CA ATION ❑ COUNTY AGENCY ❑ FEDERAL AGENCY IVIDUAI ❑ COUNTYY-AGENCY CITY NAME STATEZIP CODE SITE PHONE#,WITH AREA CODE NT$C cA 6-3 TYPE OF BUSINESS: ❑ 2 DIS TOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # ❑ 1 GAS STATION FARM 5 OTHER RESERVATION or - #of TANK'#❑ TRUST LANDS ❑ 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#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toirrdicale D PARTNERSHIP D STATEAGENCY D CORPORATION D LOCALAGENCYD FEDERAL-AGENCY D INDIVIDUAL D COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION / MAILING or STREET ADDRESS ✓Box la iodiwle D PARTNERSHIP ❑ STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE EE = = I I I //_ D -7 CURRENT LOCAL AGENCY FACILITY ID#D APPROVED BY NAME PHONE OF WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LIDE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED </ a3,a 3, YES NO __6 1d 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 CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) ` . DATA PROCESSING COPY