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I . 'T...-" T•• ,.. .....nar ,,..wr a P " : STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 5�x� .iFe FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o V COMPLETE THIS FO'�RJF)OR EACH FACILITY/SITE °'�r.oa.ae MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I.a ONE ITEM ❑ 2 INTERIM PERMIT ❑d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE � I.FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) v CD FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓8wM0dIioR ❑ PAATNBl4NP 0 STATE AODKY IC / 0 OOFPORATON 0 LOCAL AGDO 0 FWAL-AGENCY AJ/1JE4- 0 IN Wk 0 tDUM-AGI CITY NAME STATE ZIPCODE SITE PHONE N,WITH AREA CODE CA TYPEOFBUSINESS: ❑201SMBUTOR ❑N PROCESSOR ✓Bo%B INDIAN EPA ID a ❑ ❑ ❑ TRUSTYLA ION Of ❑ N of TANS'# I GAS STATION S FARM 5 OTHER A7 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 NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CDDE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNFASHIP 0 STATE-AGENCY 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 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. ❑ 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 N AGENCY N FACILITY ID N #of TANKS at SITE UE = = 1010 c� oo CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME? .`{ PHONE N WITH AREA CODE za V� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-0ISTRICT CODE BUSINESS PLANFILED NO ❑ DATE � YES CHECK# 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(3-2-081 .�, DATA PROCESSING COPY ....