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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 m ; COMPLETE THIS FORM FOR EACH/FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EV5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF yADDRESS INFORMATION rilrk- tl( rip CEJC ADDRESS NEAREST CROSSSTREET ✓Bdbitiub D PANRIETGW D STATEAGE&O 20 D 0DWORATION DCA LOAGENCY D FEDFW.-AGFAY _ / [J N]MOLWL D W RM AGENCY CIN NAMESTATE ZIP CODE SITE PHONE N,WITH AREA CODE a 00" CA Z - Ez-170(7 TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID N _ If M TANK' F-15 OTHER I GAS STATION ❑ 3 FARM ❑ RESERVATION or F-1AT THIB 817E TRUST LANDS 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 Qrk GP NIGHTS: NAME 4ST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE Z1 —O G' 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAn%W 05 CARE OF ADDRESS INFORMATION 1 MAILING or STREET ADDRESS ✓Box to lnd,c to D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ❑ 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 or STREET ADDRESS ✓Box toIftcate D PARTNERSHIP D STATE AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING 1BNICH ABOWS ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: 1. 11. ❑ III.❑ 771 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY CONTY R JURISDICTION E AGENCY R FACILITY ID R N of TANKS M SITE Y ] = OOO CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE a WITH AREA CODE L PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE SUSINESS PLANFILED DATE FRED Z3 YES ❑ NO ❑ p CHECK t PERMIT AMOUNT SURC GE AMOUNT FEE CODE RECEIPT M 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�^-� j 1� - FORM A(3-2A ) 11