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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM sl .. �' sl FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �' 110 COMPLETE THIS FORM FOR EACH FACILITY/SITE `'A�Fo�`" MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANE OSED SITE r ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 'r FACILITYS/SITEl NAM CARE OF ADDRESS INFORMATION A 40 i ADDRESS NEAREST CROSS STREET ✓130WIN IM 0 PAUSESIM 0 STATE AGENCY ❑ CORPORATION 0 LOLL-AGENCY 0 FEDEBALAGENCI' ❑ INDMDIX 0 COU"AGENCY CITY AM STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS: ❑ p _>JRIBUTOR ❑4 PROCESSOR I '/Box it INDIAN EPA ID a N 01 TANK'a ❑ I GAS STATION 3 FARM ❑ 5 OTHER TRUSRESEATION or TE o ❑ ATTHIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(UST,FIRST) PHONE M WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAM T, I TI PHONE 4 WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP Cl STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME - STATE ZIP CODE PHONE 1.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. it. ❑ 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 N JURISDICTION K AGENCY N FACILITY IDN 4f O 60 N of TANKS at SITE ml = CURRENT LOCAL AGENCY FACILITY APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO CHE N I 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-BB) +► DATA PROCESSING COPY ,^)