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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 4 YeP` Y U 4Vr FORM `A': UNDERGROUND STORAGE TANK PROGRAM so SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �- COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANE ED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5� r I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) t71 FACILITY I CARE OF ADDRESS INFORMATION ADDRESS NEAR STCROS55T EE ✓8o�ta i,giate 0 PARTNERSHIP 0 STATEAGENCI ❑ CORPORATION 0 LOCALAGENCY ❑ FEDERAL AGENCY 4c 0 INDIVIDUAL 0 COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE b,WITH AREA CODE S G CA oZ 6 3 7 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR 77T.I INDIAN EPA ID u RESERVATION or M of TANK's ❑ i GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE p EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATI N & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Intlicate 0 PARTNERSHIP 0 STATEAGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - UST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to'mGlcate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME ATE ZIP CODE PHONE B,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGA OTIFICATION AND BILLING: 1. ❑ If. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE ST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION M AGENCY R FACILITY ID N R of TANKS at SITE ® = = 1010d 1 1600O CURRENT AL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE N WITH AREA CODE b10 PERMIT NUMBER PERMIT APPROVAL DATE ±PEAMIT EXPIRATION DATE LOCA ON ODE CENSUS TRACT SUPERV R-DISTRICT CODEINESS PLAN FILED DATE FILED 3 / a YES ❑ NO ❑ CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY. U— 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 ONLx FORMA(3-2-88) [\�\V\�` �w DATA PROCESSING COPY 'An/