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Sf'iu Ot�''�f III STATE OF CALIFORNIP-v WATER RESOURCES CONTROt.-60ARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' 10 // COMPLETE THIS FORM FOR EACH F ITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE w ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE I„a 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 0 FACILITY/ ;2E CARE OF ADDRESS INFORMATION ADD SS NEAREST CROSS STREET ✓ 0 PARINEMP 0 STAR AGDO TON 0 LOCAL-AGENCY 0 FEOE K AGENCY #CNIWAL 0 COLNIY AGENCY CITY NAME STATE ZIP CODE SI EPHONE 0.WI AREA CODE CA TYPE OF BUSINESS. 2 IBUT011 1 PNOCESSOfl ✓Box i11NDIAN EPA ID N _ No1 TANK'a ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: ME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE IlIGHTS: NAME(UffT,FIR HON #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS—(MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION MAILINGor STREET ADDRESS I/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY /// 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY Cl INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE 21P CODE PHONE N,WITH AREA CODE 1,531,962, 336/ Ill. TANK OWNEK 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 ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. wr 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 M JURISDICTION R AGENCY M FACILITY DM- - M of TANKS at SITE ml = = d 1d a 3 I of s z CURRENT LOC#H-I�A AGENCY FACtUTrDf# - APPROVED BY PHONE N WITH AREA CODE `V PERMIT NUMBER ROYAL DATE PERMIT EXPIRATION DATE LOCATON CODE CENSUS TRACT# SUPERVISOR-DISTRIC CODE BUSINESS PLAN FILED DATE FI ED .Q�V) YES ❑ NO CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 11 B 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. FJJRM A f3-2-GS) v\V//// -T� DATA PROCESSING COPY