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�Ein OF STATE OF CAL.I FO R N boC WATER RESOURCES CONTRO"eBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM fto VTE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ( COMPLETE THIS FORM FOR EACH FACILITY/SITE ` 4IIFOR NSP MARK ONLY W NEW PERMIT ❑ 3 RENEWAL PERMIT.. ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY D SITE P ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE C C C I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) Cx I F CI ITY/SITE NAME CARE OF ADDRESS INFORMATION / .4;c M A'saL ff ADDRE / NEAREST CROSS STREET ✓ b Mpte ❑ PARTNERSHIP ClSTATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CI ME �1 STATE ZL2__CODE ITE PHONE#,WITH AREA CODE CA iTYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID# #of TANK a ❑ 1 GAS STATION [:]3 FARM OTHER TRUSTRESERVLANDS ATION Or ❑ a AT THIS SITE l EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) i DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE . d ao - 3 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE I NIGHTS:#NAME(LAST,FIRST) �,�sf PHONE#WITH AREA CODE II. PRO ERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S '" MAILING or STREET AD RESS r�Box to indicate C] PARTNERSHIP 11STATE-AGENCY td Q .. / CORPORATION ClLOCAL-AGENCY ❑ FEDERAL-AGENCY ((// ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE S'�© e o fi �o - 6 III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. 0/ Ii. ❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. PPLICANT'S NAME"ED& TURE) DATE I lea LOCAL A NCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE � q 10 w a � 0 � CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE /N PERMIT NUMBER PER APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 4 9 � v`— � YES NO ❑ / CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(i)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) '—1 v DATA PROCESSING COPY �.. Q, i