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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD s` FORM A : UNDERGROUND STORAGE TANK PROGRAM SITE f`' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I COMPLETE THIS FORM FOR EACH FACILITY/SITE `" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT [Ell CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/ IT NAI CARE OF ADDRESS INFORMATION �) , ADDRESS ,^ NEAREST CROSS STREET ✓BubiiEMe Cl PARTNEBRAP 0 9A7AfaV /(.� `/l�(J Cl 11 13LOCALVENLY ❑ FEDUK4GDO ❑ INIIMWAI 0 ODUNW AGENCY CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE CA TYPE OF BUSINESS'. ❑p DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID 4 RESERVATION or P of TANK'4 ❑ t GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to mclicate 0 PARTNERSHIP 0 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 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to indlc.t. 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRBSB 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYIN JURISDICTION M AGENCY M FACILITY ID M K of TANKS B1 SITE i s I 100 CURRENT LOCAL AGENCY FACILITYJD N APPROVED BY NAME PHONE 0 WRIT AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EKPIRATION DATE LOCATION CODE CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F D _ YES � NO � (� CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: ITHIS 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-BS) \