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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EA7 FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 19 5 CHANGE OF INFORMATION F-17 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT 1:14 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE EC I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NA E Ii., CARE OF ADDRESS INFORMATION ADDRESS - NEAREST CROS STREET ✓ PbSraA Cl PARTNERSHIP 0 STATE AGENO' V317 /q// 0 ADAUT10 O L A ClDEPA.A6ENG MARY AGENCY CITYNAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE o j CA TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Boa of TANK'S RESERx if INDIAN EPA ID N ❑ ❑ ❑ TRUSTTRESERMLANDS ATION 0T ❑ AT THIS SITE I GAB STATION 3 FARM 5 OTHER EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,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(IAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING w STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP Cl STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 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 COUNTY M JURISDICTION* AGENCY M FACILITY ID R R of TANKS at SITE " CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE 0 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEDRO AA ../ s— I YES NO 3 V CHECKK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: e THIS FORM MUST BE ACCOMPANIED BY AT LEAST 111 OR MORE TANK PERMIT FORM 'B'APPLICATIONISI, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY FORM A(3-2-88)