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STATE OF CALIFORNIO WATER RESOURCES CONTRO,OARD FORM `A': SITE UNDERGROUND STORAGE TANK PROGRAM / ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY S SITE f\ ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C C I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) C C FACILITY/ NAME CARE OF ADDRESS INFORMATION ADDRESS ^� ) NEAREST CROSS STREET ✓Sp,k rWok Cl PARTNERSHIP 13STATEAGENIX , ❑ ComomL� C2 Cl LOCAL AAGENC C3 FEDERAL AGENCY NOMCITY NAME / STATE ZIP CODE SITE PHONE N,WITH AREA CODE IVJ CA TYPE OF BUSINESS: ❑ 3 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID p ❑ 1 GASSTATION 3 FARM ❑ 5 OTHER RESERVATION or ❑ M of HIS SITE TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY 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 III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to I,d,c.t. ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL C 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. ❑ if. ❑ 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 M JURISDICTION N AGENCY N EACILATY10 N It of TANKS at SITE c� � CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE11, 'r �A ^I PERMIT NUMBER PERMIT APPROVAL PERMIT EXPIRATION DATE LOCATI //E� CENSUS TRACT N SUPERVISOR R--OIST��R17C\T CODE BUSINESS PLAN FILED DATE FILED VI 2I /r / VES CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: U 1 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. v✓ FORMA g81-N '� ✓/)/ �� /��V DATA PROCESSING COPY