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F CALIFORNIWATER RESOURCES CONTR�B9RD yE"` OF f STATE O 91 * FORM `A': UNDERGROUND STORAGE TANK PROGRAM 'gym SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE FORN P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Fill 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ' I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME ;'t� CARE ADD ESS INFORMAT ON — (A I ADDRESS NEAREST CROSS STREET ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY dam/ ❑ INDIVIDUAL ❑ COUNTroUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE cA - o 366 -- -L 6 el-7 TYPE OF BUSINESS. ❑/yDISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a N of TANK'S El GAS STATION [03 FARM El OTHER TRUSTESERVATION VLANDS of 1:1AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: AME(LAST,FIRFT) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE At WITH AREA CODE ` n Zf7 NIGHTS: NAME(LAST,FIRST) PHONE U WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION v/Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS ✓Box to indicate El PARTNERSHIP ElSTATE-AGENCY []'CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS ___t CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. II. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION# AGENCY N FACILITY ID�E��7 N of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID k APPRO E6BY RAME PHONE 0 WITH AREA CODE PERMITNUMBIER P OVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL � J� YES ❑ NO ❑ Y CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k 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 ONL , FORMA(3-2-88) •