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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM t1 �o SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E OS ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITYISITE NAME G N z / / \ • CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROS STREET ✓embignle Cl PANiNEASHIP El STATE AGENCY o M� a OYO d Ila i `L � ❑ FEDEMI.AGM CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE fie' CA TYPE OF BUSINESS'. ❑2 DISTRIBUTOR ❑ "PROCESSOR I '/Box if INDIA EPA ID N RESERVATION or •M TANKF ❑ 1 GAS STATION [:]3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE U EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. AME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE l 8 - r NIGHTS: NA (LA .FIRST) / PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl CORP RATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ 1 IDUAL ❑ 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 ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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 AMISS 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# JURISDICTION E AGENCY R FACILITY ID R N of TANKS N SITE CURRENT LOCAJ AGENCY FACILITY ID N APPROVED BY NAME PHONE•WITH AREA CODE �e O PERMIT NUMBER PERMIT APPROVAL DATELCODE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT E SUPERVISOR-DISTRBUSINESS PLANFILED DATE FILED VES [] NO 4FCHECK• PERMIT AMOUNT SURCHARGE AMOUODE RECEIPT BY:C 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 07FORM A(3.2-SB)