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FBI STATE OF CALIFORNIA• WATER RESOURCES CONTROL PARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PER NENTLY CLO D SITE F"'a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE W I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N FACILITY/SITE NAME CARE OF ADDRESS INFORMATION �- 0� dnIecc ADDRESS NEAREST CROSS STREET ✓MvIS iMirale Cl PARTNERSHIP D STATE AGENCY Q t� -f m U�� D CORPORATION 11 LDGL AGENCY D FEDERAL AGENCY t� D INDIVIDUAL D COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR I I/Box if INDIAN EPA ID # #oI TANK'e E] 1 GAS STATION [:] 3 FARM E] 5OTHER TRUSTYLANDSATION o ❑ 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(UST.FIRST) PHONE#WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to'mtli,,.W 0 PARTNERSHIP 0 STATEAGENCY ❑ CORPORATION 0 LOCALAGENCY0 FEDERALAGENCY D INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE HONE 4,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to lndlcate 0 PARTNERSHIP D STATE AGENCY 0 CORPORATION D LOCAL-AGENCY D FEDERAL AGENCY D INDIVIDUAL ❑ COUNTYAGENCY 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. it. ❑ 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# JURISDICTION# AGENCY# FACILITY ID At #of TANKS at SITE = = = I pU I I `4 1 Ll 191 101 (Jo 101 CURRENT LOCAL AGENCY FACILITY ID# M A n-rE a-a PHAPPROVED BY NAME ONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILED C/p V �� (l �, ' YES NO 1 7 b 1 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 INFORMATION ONLY FORM A(3-2-88) , DATA PROCESSING COPY