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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 'Yx'""`' YN. A FORM 'A': A: UNDERGROUND STORAGE TANK PROGRAM "m SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY F-1I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITENAME ,g CARE OF ADDRESS INFORMATION 'Set I (clC0,0222hN Q ADDRESSp NEAREST CROSS STREET ✓Bmiowool 0 PAl7iNER41P 0 STAN-AGENLY 0 COW MTCN 0 LOCA-AGENCY 0 FEDSW AG90 o ❑ INWDJAL ❑ WUNTYAGENC( CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE 5-7461 CA TYPE OF BUSINESS ❑p DISTRIBUTOR ❑4 PROCESSOR I ✓Box if INDIAN EPA ID N N of TANK'S ❑ ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION orTRUST LANDS AT THIS SITE 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(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate D PARTNERSHIP D STATEAGENCY D CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATE-AGENCY Cl CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY D 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: 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUTrnNTY R JURISDICTION R AGENCY R FACILITY ID R N of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID NID N APPROVED BY NAME PHONE N WRN AREA CODE SEi PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LL CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DApTE (LED YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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. FORMA(3-2-SB) 7