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STATE OF CALIFORNITC WATER RESOURCES CONTRAOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM � N SITE ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ! �Y COMPLETE THIS FORM FOR EACH FACILITY/SITE o "" MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE !A� Z 10 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE 6 NAME g CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bax to iWule ❑ PARTNERSHIP ❑ STATE AGENCY CO ❑ CORP��ggAATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY CA fd�IIPfI�OUAL ❑ COUNTY AGENCY V A CITY NAME STATE ZIP CODE S TE PHONE 4,WITH AREA CODE CA S 1-0 -27- /6 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID 4 RESERVATION or #of TANK's ❑ 1 GASSTATION ❑ 3 FARM - OTHER TRUSTLANDS ❑ � AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE r' ay .3�Z~3bP3 NIGHTS: NAME(LAST.FIRST) PITONE 4 WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or BTREET ADDRESS I/Box to lodl.te ❑ PARTNERSHIP ❑ STATE-AGENCY 0 GO ORATION 11LOCAL-AGENCY 1-1FEDERAL-AGENCY (JJJ IVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to in0¢ate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,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. ❑ 1L 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 Al AGENCY# FACILITY ID a #of TANKS at SITE 0G CURRENT LOCAL AG CY FACILITY ID# APPROVED BY NAME PHONE If WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE � PERMIT EXPIRATION DATE LOCATION C E CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED _ YES E] NO 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