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STATE OF CALIFORNT WATER RESOURCES CONTRBOARD sE FORM `A': UNDERGROUND STORAGE TANK PROGRAM Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,; go COMPLETE THIS FORM FOR EACH FACILITY/SITEffF i MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMAN TLV OSED SITE M'a ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT Eli TEMPORARY SITE CLOSURE 1.FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) U) CA) FACIUTV/SITE NAME CARE OF ADDRESS INFORMATION A NEAREST CRO STREET /� ✓ naivete Cl PAAINBEAIP 0 STATEAGENCY I . 1n �- // fAFPOAAnoN ❑ LOCAL AGENCY ❑ FEOEPAI AGENCY l LK. ❑ INDMWAL ❑ WUNIY-AGENCY CITY NAME STATE 21P CODE SITE PHONE 11,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑I y4 PROCESSOR -/Box if INDIAN EPA ID p Moi TAMC# ❑ I GAB STATION ❑3 FARM u 'OTHER TRUST LANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSO PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATIO & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE III. TANK OWNER INFORMATION &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 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE it,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH L GAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER, AND TO E BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION R AGENCY R FACILITY ID If If of TANKS at SITE F3a 7 0 03 CURRENT LOCAL AGENCY FACILITY ID k APPR V BY AM PHONE#WITH AREA CODE FIR E Qa PERMIT NUMBER PERMIT APPROVAL DIF PERMIT EXPIRATION DATE a LOCATION CODE CENSUS TRACT F SUPE VISOR-DISTRICT CODE BUSINESSPLA FILED DATE FILED 0 31YES ❑ NO — 1 00 CHECK• PERMIT AMOUNT SURCH OEAMOUNT FEE CODE RECEIPT# BC THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) �# DATA PROCESSING COPY ,�