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STATE OF CALIFORNIA WATER RESOURCES CONTROL BQARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAMV ate' S! FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMI7 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDSITE 1-16 ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) p FACIL TY/SITE NAME CARE OF ADDRESS INFORMATION GU/V ADDRESS NEAREST CROSS STREET ✓Boetokdicate ❑ PARTNERSHIP ❑ STATE AGENCY .i //I ❑ CORPORATION ❑ LOCALAGENCY EIFEDEPALAGENGY W i / (/�/ Cl INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP DE SITE PHONE p.WITH AREA CODE CA .5a O r TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 OCESSOR ✓Box if INDIAN EPA ID a If RESERVATION or ❑ �A'av�A 0 AT THIS SI ❑ I GAS STATION ❑3 FARM TANKS 5 OTHER TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYSNAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE S ccs awl So {ro i NIGHTS: NAAE(LAV,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE -3 611YK-el II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Stele ore MAILINCf rSTREET ADORE ✓30.10 Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY YPDRATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ©, v/ jV f ENDVUAL ❑ COUNTY-AGENCY CITU NAM EI.-„_ `O /� ST ZIP CODE ® C PHONE a,(p (AWITH AREA CODE 1�� 111. TANKOWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION .S't1,nAz a � MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CNECK ONE(I)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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCYII FACILfTYID 11 - #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAM ---_ PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L OCATION CODE CENSUS TRACT 0 SUPERVISOR-D�R�CODE BUSINESS PLAN FILED DATE FILED IS I Q�j YES E] NO E] I/ � �f N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# Y: 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) 0- DATA PROCESSING COPY