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STATE OF CALIFOR& WATER RESOURCES CONTROL BOARD FORM 'A': s �--� UNDERGROUND STORAGE TANK PROGRAM 4 SITE � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Ej 7 PERMANENTLY CLOSED SITE fJ ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 53 FACILITY/SITE NAME (—t TiS�U� CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓BmbiMul, 0 PARTNERSHIP 0 STATE AGENCY 7 • ��/� 0 ICOWRtN11DN Cl WCk.-AA AaCy 0 FEDERALAGENCY CITY NAME , ^ STATE ZIPCODE �(/� SITE PHONE p,WITH AREA CODE TYPE OF BUSINESS: CA D 2 DISTRIBUTOR Ej 4 PROCESSOR ✓Box it INDIAN EPA ID N 1 GAS STATION 0 3 FARM 5 OTHERRESERVATIONor ❑ p of TANK's TRUST IANOS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,HHST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LA5T,FIRST) PHONE p WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING M STREET ADDRESS x/BOX to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE If.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 STATEAGENCY0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY�AGENCY CITY NAME STATE 21P CODE PHONE p,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. 0 IL 0 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 k JURISDICTION N AGENCY# FACILITY ID# #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID Y APPROVED IS NAME MPRONE As WITH AREA CODE PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT p SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED GATE FILED YES E] NO CHECK p PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM '8'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY... p FORM a(3-2aa) • W\\ . DATA PROCESSING COPY