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STATE OF CALIFORNIA WATER RESOURCES CONTRbt'BOARD a FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION100 COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE N ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 00 00 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) CA FACT /SITE NAME CARE OF ADDRESS INFORMATION 1 ADDRESSNEARESTGROSS STREET ✓ WF 0 pmm4BBNP 0 STATE AGM 1A7. l c dh 0DWWTIGN [2 =k-AGeIa ❑ FED A.AGM INDMDG 0 CCu IYAGOICT CITY ME STATE ZIP C DE S PMOM,WITH AREA CODE CA 3 s TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box#INDIAN EPA ID R If W TANKS ❑ 1 GAS STATION E:]3FARM Ue`6THER TRUSTVATION LANDS BI ❑ ATTHISSfTE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) HONE R WITH AREA CODE DAYS: E(IAST,flRST) _ HONE p WITH AREA CODE NIGHTS: NAME(LAST.FIRST PHONE X WITH AREA CODE NIGHTS: NAME( FIRST) PHONE X WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING a STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODEPHONE p,WITH AREA CODE I OWNER INFORMATION &ADDRESS— MUST BE COMPLETED) III. TANK O O (II NAME S CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓BoxCO to indicate ❑ PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 13FEDERAL-AGENCY ❑ INDIVIDUAL 11 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE X,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: L ❑ IL ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION X AGENCY V FACILITY ID 11 B of TANKS at SITE CUR LOCAL AGENCY FACILITY ID p APFp6VED BY NAME PHONE♦WITH AREA CODE PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FLED{��Y/(y= YES NO �WA} - CHECK M PERMIT AMOUNT SURCHARGE AMOUNT 7 EE CODE RECEIPT x BY. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORM A 13-2-SSI DATA PROCESSING COPY �y.