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STATE OF CALIFORNIA WATER RESOURCES CONTR'M BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM �a SITF, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m PA I COMPLETE THIS FORM FOR EACH F ITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN NTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION SSG � ADDRESS NEAREST CROSS STREET ✓BarbMdemi ❑ PARTMWIP ❑ STATE AGENCY ❑ 07WMPGN ❑ LWAAGENCY ❑ FFDFAAl- f ❑ INGNIDUAL ❑ COUNTYAGENCY CITY NAME $TATCA ZIP CODE SITE P Ny3 AREA CODE TYPE OF BUSINESS'. [-]2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID p ((� 1-603 _ N RESERVATION or ❑ of TANK? ❑ 1 GAS STATION El FARM OTHER TRUST LANDS / Liv v�—�- ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) - PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE Caou `t31Jvo NIGHTS: NAME(LAST.FIRST)' n PHONE IF WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE P WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME / CARE OF ADDRESS INFORMATION t-C MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL O 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 STREET ADDRESS I/Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE A SS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 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 N JURISDICTION K AGENCY M FACILITY ID M R of TANKS a1 SITE ler / CURRENT L Y FACILITY ID N APPROVED BY NAME PHONE N W ITN AREA CODE v 1 PERMIT NUM ROVAL DATE PERMIT EXPIRATION DATE LOCA NCODE CENSUS TRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN❑FILED NG ❑ DATAFILEO4 3A A A� of CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: 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(3-2-18B) usf/ F� -fa&h, ��e� fie: