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STATE OF CALIFORNT"A WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM IL SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION }" o - COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•o»�"- MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PER CL 'SITE 1-i ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ) µ I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 00 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bmwitswe 0 PAHTNERW 0 STATE AGENCY ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL M ENCY 0 NDMOUAL 0 COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N ❑ I GAS STATIN ❑ 3 FARM 5 OTHER TRUSTYLANDS ATION dl ❑ Nof AT THHISIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST,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 N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING w STREET ADDRESS ✓BOA to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box w inoicate 0 PARTNERSHIP 0 STATE-AGENCY O CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY ❑ INDIVIDUAL 0 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 ADDRESS 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 COUNTY01 JURISDICTION a AGENCY K FACILITY ID B M of TANKS at SITE -EE = = I I I �/- t-5- 13l I I I El CURRENT LOCAL AGENCY FACILITY ID�13 APPROVED BY NAME PHONE a WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L E CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILE23, YES NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTS Y: 1}115 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. _)_01 FAA(3-2-SB) �O DATA PROCESSING COPY