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STATE OF CALIFORNI19 WATER RESOURCES CONTRCGOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM u +fie SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE °+t�Foax�n MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT FS rCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE [7� I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 7 /SIT N E CARE OF ADDRESS INFORMATION ADDRESS N EST CROSS STREET ✓BOXIO Qi 13 PARTNERSHIP ElSTATE AGENCY N ❑ COWORAPON ❑ LOCAL AGENCY ❑ FEDERA,AGENCY ❑ INDIVIDUAL ❑ 000N1Y.AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE 426 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID * ❑ 1 GAS STATION ❑3 FARM �OTHER TRUSTLANDS or ❑ ATTHIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NA (LAST,FIR1ST) PHONE*WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION a MAILING or STREET AD ORES ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ ERA - GENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NA STATE ZIP CODE PHONE If,WITH AREA CODE tAJXNV Sl 08- ,2 III. TANK OWNER NFORMATION &ADDRESS— (MUST BE COMPLETED) Noss) -735- 19 -1 1 NAME CARE OF ADDRESS INFORMATION S I MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY _ ❑ INDIVIDUAL ❑ 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 LEGAL NOTIFICATION AND BILLING: I. Rr 11. ❑ 111.❑ 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 If AGENCY* FACILITY ID* *of TANKS at SITE o 2- 1 d d CURRENT LOCAL AGENCY ACILITYID* APPROVED BYNAME PHONE M WITH AREA CODE PERMIT NUMBER JJ`` PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT If SUPERVI8O -/DISTID T CODE BUSINESS PLAN FILED DATE FILED cam/ © .23A a V L YES NO-E— CHECK* 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 A CHANGE OF SITE INFORMATI' FORM A(3-2-88) DATA PROCESSING COPY