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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 19 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SIT O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE W I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) W FACILITY/SIT NAME CARE OF ADDRESS INFORMATIONW ADDRESS NEAREST CROSS STREET ✓Bm biHcae ❑ PAATNERSNIP 0 STATE MENCY Ivy` /(J� ❑ CORPO,TANON 0 LOCI AGENG( 0 FEDERAL ❑ INOMDML 0 COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA I / TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box tt INDIAN EPA ID # #of TAI RESERVATION or AT THIS SITE O ❑ I GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(I-AST.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#WITH AREA CODE IL PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME .! CARE OF ADDRESS INFORMATION MAILINGwST14EET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME ' STATEC/ ZIP ODE PHONE#,WITH AREA CODE P 9 - �i > III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boa to iaEicale 0 PARTNERSHIP 0 STATEAGENCY Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK 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 R JURISDICTION M AGENCY R FACILITY ID K R of TANKS at SITE CUR NCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE RENT LOCAL AGE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA N CO [CENSUS TRACT 0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE !UD`17 YES ❑ NO ❑CHECK# MIT AMOUNT SURCHARGE AM UNIT FEE CODE RECEIPT# 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. FORM A(3-2-68) H -61 DATA PROCESSING COPY #v,