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STATE OF CALIFORNIA- WATER RESOURCES CONTROL-6OARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE J4I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION DCOMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION Z ANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 6 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME., CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓ R CI PARTNERSHIPEl F CUIPOTION GENEl FEDERAL AGENCY � f. ❑ IN7NIdJAL ❑ WUNT(AGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE CA s 36 ' S- S -3 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P SSOfl I/Box it INDIAN EPA ID If RESERVATION or ❑ Nof TANK'# ❑ 1 GAB STATION ❑ 3 FARM ❑5 OTHER TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE L'n✓ NIGHTS: NAME(LAST,FIRST) PHONE N 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 or STREET ADDRESS ✓Boxmintlicale 0 PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicata 0 PARTNERSHIP 0 STATEAGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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. ❑ I. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY IDN N of TANKS N SITE a�l = = o CURRENT LOCAL AGENCY FACILITY1D N `� APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER IL'() U PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENBUS TRACT N SUPERVISO111"' CT CODE BUSINESS PLAN FILED DATE FILED p` !Lz' v YES NO j CHECK# PERMITAMOUNT SURCHARGEAMOUNT FEE CODE RECEIPT# By: n / 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 ON N FORM A(3-2-8111)