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� 5"ru Oil f�f STATE OF CAL_ IFORNI WATER RESOURCES CONTRO �L BOARD FORM `A': itUNDERGROUND STORAGE TANK PROGRAM �e SFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C/ COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN) SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE LO I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITV/SIT NAME CAPE OF ADDRESS INFORMATION ADDRESS (} NEAREST CROSS STREEFI ✓BabinkA, ❑ PARTNBIRIP ❑ STATE-AGENCY arY INDMWAI 0 OD��AGEN FEUENl-AGENCY CITY NAME S ATE ZIP CODE SITE PHONE N,WITH AREA CODE S ' CA TYPE OF BUSINESS: [36DIS!"RIBUTOR ❑4 PROCE"0' ✓Rox"INDIAN EPA ID N RESERVATION or Fol TANMt ❑ I GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAY-Z(LA T.FIRST) PHONE"WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE ero a09 31 a / NIGHTSNAME(LAST,FI ) PHO E N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME JSCARE OF ADDRESS INFORMATION r MAILING or STRE&ADDRESS ✓Box to mclicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL Cl 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 MAILING or ST EET ADDRESS ✓Bon to md,cate 0 PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ 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 ADBRBBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION E AGENCY S FACI N of TANKS at SITE CURRENT A NCY FACILITY ID E dAPPROVED BY NAME PHONE N WITH AREA CODE �� r PERM NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAE CENSUS TRACT 0 S E111 '-DISTRICT CODE BUSINESS P$N❑FILED ND ❑ DAM FI� ��uGfJ a 3 a- I PERMR AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT E BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-N)