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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PIE C E I-+ ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE —4 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION O PmYp. V'O � l'Vi (tip ADDRESS ',,/ NEAREST CROSS STREET ✓BNbigRll D PANINEASW D STATE AI CY (e7o V\ t C lv FR�svw DDNIWII� DD ` MENa D MIL AMC CITY NAME STATE ZIP CODE SITE PHONE N,WITH RFA CODE S-IILu/ CA rJi 7.0� �C Zs TYPE OF BUSINESS. ❑2 DISTWOR ❑4 PROCESSOR I ✓Boa it INDIAN EPA ID N ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSRT LANDS VATION w ❑ ATTHIIS SITE (/ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME("ST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE U. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING w STREET ADDRESS ✓Boa to Indicate D PARTNERSHIP DSTATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEOERAL-AGENCY D INDIVIDUAL D 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 w STREET ADDRESS ✓Boa to indicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CIN 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. ❑ 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 R AGENCY B FACILITY ID a k of TANKS N SITE vnNAME CURRENT LOCAL AGENCY FACILITY ID N APPROVEPHONE N WITH AREA CODE N !. PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATgION CODE CENSUS TRACT N SUPERVISOR-DISTR;17 CODE BUSINESS PLAN FILED DATE FILED q ( ; 3,ffo y YES El NO I-] CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTS 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. 1 NORM A(3-2-65) DATA PROCESSING COPY .