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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD m ^ FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FA ITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION E] 7 PERMANENT �O ITE ❑ 6 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT TEMPORARY SITE CLOSURE cJ` I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) FAcaInYSR n1AME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓BPIbNrreN ❑ HJUMER i ❑ SIATE-AGDO ❑ OMFOMTON ❑ LDXI AGEMCY ❑ jE EW-AUNO, CITY NAME ❑ N:IvOD ❑ CQNTY.AGENGY STATE ZIP CODE SITE PHONE N.WITH AREA CODE CA TYPE OF BUSINESS: ❑2 DISTNUTOH ❑N PRDCES50R ✓BON II INDIAN EPA ID N E] I GAS STATION ARA ❑ 5OTHER RESERVATION W ❑ - FSI TANKS iT TRUST LANDS AT THIS SITE U EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AR!!!=S T.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE N WITH AREA CODE IL PROPERTY OWNER INFORMAT N &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING m STREET ADDRESS ✓Box b m cm. ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADD ESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING a STREET ADDRESS ✓BON b iMicele ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH MEA CODE IV. LEGAL NOTIFICATION AND BILLING ADDR SS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD E USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. 11. ❑ 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION B AGENCY B FACILITY ID F B of TANKB AI SITE CLQ CCD � � 07 a � � CURRENT LOCAL AGE CY FACILITY IDN APPROVED BY NAME PHONE 6 WITH AREA CODE YBEA PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODEB TRA` CT N EUPERYIBOR-DISTRICT COOK BUSINEBB PLAN FILED DATE FILED 9 I NO CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTS BY; R. \ V THIS FORM MUST BE ACCOMPANIED BY AT LE"'11)OR MORE TANK PERMIT FORM 'B'APPLICATION(S). UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-4418)