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STATE OF CALIFORNIA' WATER RESOURCES CO STATE FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z $ITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' o G COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT RANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE, I"a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I p_a 1.FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) CA) j FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ~ ADDRESS NEAREST CROSS STREET ✓ ❑ PAATNEASHIP ❑ STATE AGENCY TION Cl LOCAL CMNTrGENLY ❑ FlLBNL AGENCY ❑ ADMIRAL ❑ CGUNtt AGENC! III CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE cA 9533 3-2/b TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 P R ✓Box iI INDIAN EPA ID N _ #of TANW6 41 RESERVATION or IS [—] I GMSTATION ❑3 FARM OTHER TRUBT LANDS El �__ AT THSITE ISI EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: AME UST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE CA a3 NIGHTS: NAME(W,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓BoxtoinEicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/Box to indicate ❑ 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. ❑ II. ❑ IS.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION R AGENCYIN FACILITY ID# #of TANKS at SITE ® / � CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE A �I O/ /A�— PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIONCO E CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI U O O / YES 0 NO �c! �3 CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. / / FORM A(3-2-88) W ,..• DATA PROCESSING COPY -...