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STATE OF CALIFORNI.0 WATER RESOURCES CONTRCAOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 21 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 J! I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS / I NEAREST CROSS STREET ✓Sw Ponou 0 PARTNERSHIP 0 STATE AGENCY S. I 0 CORPORATION D LOCI AGENCY 0 FEDERAL-AGENCY D INOrv10UAL D CAUNiRAGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE 1 b f-� CA TYPE OF BUSINESS2 OISTRISL1TOfl 4 PROCESSOR I/Box if INDIAN EPA ID N N of TANK'N ❑ ❑ RESERVATION or ❑ 1 GAS STATION F-1El3FARM ❑ 50THER TRUSTLANDS ATTHISS TTE 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 -V 80.to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL Cl COUNTYAGENCY 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 indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY D FEDERAL AGENCY D INDIVIDUAL 0 COUNTY-AGENCY CIN 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: 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 R JURISDICTION R AGENCY M FACILITY IDK N of TANKS N SITE " CURRENT LOCAL AGENCY FACILITY IDM LAPPROVED NAME PHONE M WIT14 AREA CODE 5W R_� S PERMIT NUMBER PERMIT APPROVAL DATEPERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACTN SUPERVISOR•DISTBUSINESS PLAN FILEDDA FILYES NOPERMIT AMOUNT SURCHARGE AMOODE RECEIPT BY: ±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./ / FORM A(3-2-88) 0 0 (/\