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or STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION d: COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLYCn ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE T I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/'�/S�I{TE NAME CARE OF ADDRESS INFORMATION ADDRESS ( NEAREST CROSS STREET ✓Bonow,alt, 0 PARTNIMP 0 STATE AGENCY ZZiO 0 0ORPORATION 0 LOCK AGENCY 0 FEDERAL AGENCY ❑ INDNIDUAL 0 =xTYAGENOY CITY NAME ` STATE ZIP CODE SITE PHONE#,WITH AREA CODE M1\A CA TYPE OF BUSINESS: 2 DISTRIBUTOR 4 P OCESSOR Bad INDIAN EPA ID # Nof TANK'S ❑ ❑ aa RESERVATION w ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#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 II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS 4/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL ❑ 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 q pr MAILING or STR ET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. II. ❑ Ill.❑ 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# AGENCY# FACILITY ID If ` ' #of TANKS at SITE CURRENT LOCAL AGENCZ Y FACILITY ID• APPRO PHONE N W NTH AREA CODE PERMIT NUMBER Z PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LLOCATIONCODE CENSUS TRAP, N SUPERVISOR•DISTRICT CODE BUSINESS PUIN FILED DATE LED qCA �� v YES NO El PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OP"IRE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) JI '.. fes%' DATA PROCESSING COPT"