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STATE OF CALIFORNIA WATER RESOURCES CONTRAIDARD a�. FORM A: UNDERGROUND STORAGE TANK PROGRAM �o slt FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ftloor 60 ADDRESS W , NEAREST CROSS STREET ✓i3,Nb uIe ❑ PAIffNE1911P ❑ STATE AGENCY ❑ WA'GRATON ❑ LOCAL-AGENCY ❑ FEDERALAGENCYO INDIVIWAL ❑ COUNTY AGENCY CITY NAME , STATE ZIP CODE SITE PHONE p WITH AREA CODE �K CA aog dog X66 -573-5 TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PRO ESSOR ✓Box if INDIAN EPA ID if ❑ r It of TANK's 1 GAS STATION ❑3 FARM OTHER TRUSTYLANDS ATION d ❑ Y w ""' 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 q — NIGHTS. NAME(LAST,FIRS ) PFIbNE#WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE II 11. PROPERTY OWNER INFORMATION &IADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS —)MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOYB ADDRESS SHOULD BE USED FOR BOT LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION Al AGENCY M FACILITY IDM N of TANKS M SITE M = = I I 1 / 1717131 101o0 12J- -CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE /V Dore PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACTQM j SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL4INFORMAnONONLY. 3A NA �a YES NOCHECK# PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT#THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE �IFORM A(3-2-88) .