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STATE OF CALIFORNIA' WATER RESOURCES CONTROeBOARD FORM 'A': SITE UNDERGROUND STORAGE TANK PROGRAM mom' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION . . COMPLETE THIS FORM FOR EAC ACILITY/SITE1„o YEA MARK ONLY Ll1 NEW PERMIT ❑3 RENEWAL PERMIT ~ ONE ITEM 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE ❑ 2 INTERIM PERMIT ❑q AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE (/�J 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITYISITE NAME 'N ) CARE OF ADDRESS INFORMATION rel rim ADDRESS NEAREST CROSS STREET ✓ FABH Bsbxdrao 0 PAWNP 0 STATE-AGDO 266 erofcNa2 Cl cOWwaATON ❑ LOCALADB,LY 0 FBXNALAG00 CITY NAME 0 INDADIAL Cl ODIPM AGENCY STATE ZIP CODE SITE PHONE N.WITH AREA CODE CA TYPE OF BUSINESS: F-1 p DISTRIBUTOR F-1 4 PROCESSOR v'Box N INDIAN EPA ID N ❑ I GAS STATION F-] 3 FARM ❑ 5 OTHER RESERVATION or ❑ - N of TANK'F 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 NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS %/ft.to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to Iftcale 0 PARTNERSHIP 0 STATE-AGENCY 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. ❑ 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 N AGENCY R FACILITY IDN M of TANKS at SITE 11 // " / f 1d6__> V CURRENT LOCAL AGENCY FACILITY ITTY ISD N APPROVED BY NAME PHONE N WITH AREA CODE tV PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE TEFILq ;; 3. TRACT N SU►ERVISOR-DISTRICT LODE BUSINESSPSNFILED NG ❑ O0'1 CHECK N PERMIT AMOUNT SURCHARGE A�M'�OUNT ME CODE RECEIPT I '�Jj!/�BY: ±l 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 FORM A(3-2418)