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��yp'rvtR'v. .. �....,'°TSNrTa'!•�ur+Pns.r.,-�'. -'eu�^�^---�..�.-,. STATE OF CALIFORNID WATER RESOURCES CONTRARIOARD *'`A FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o 1 1 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE Fi ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURElr+l �/ F' I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) F-► FACILITY/SITE NAME CARE OF ADDRESS INFORMATION I� Ts lei �N ADDRESS �—� NEAREST CROSS STREET ✓ i d.le Cl PARTNERSHIP ❑ STATEAGENCY CORPORATION Cl LOCAL AGENCY ❑ FEDERAL AGENCY ✓✓ ❑ INOIVIOU0. ❑ COUNNAGENCY CITY NAME STATE ZIP CO E SITE PHONE N,WITH AREA CODE cA �' -� j! /toy TYPEOF GASST TION ❑ pF IBIITOR ❑ 4PROCESSOR ✓Box itINDIAN EPA ID w Al of TANK's ❑ 1 GAS STATION FARM ❑ 5 OTHER TRUSTYLANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAM (LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(IAST,FIRST) PHONE H WITH AREA CODE NIGHTS: NAME(IAST,FIRST) PHONE k WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADD S �✓BJYtointlicale ❑ PARTNERSHIP ❑ STATE-AGENCY LYCORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ls� ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE ;;E p,WITH AREA CODE �S III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME le;_ CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It 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. 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# JURISDICTION If AGENCY# FACILITY ID If IF o/TANKS at SITE CURRENT LOCAL AD Y/ FACILITY IO k APPROVED BY NAME PHONE#WITH AREA CODE /�L//./JLYjCT PERMIT NUMBER �/�� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIO CODE CENSUS TRACT N SUPERVISOR-DISTRICT ODE BUSINESS PLAN FILED DATE FILED �--j YES NO 2/Q CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM 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(3-2-81 3/s), g1 0 DATA PROCESSING COPY • )