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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD A FORM `A': UNDERGROUND STORAGE TANK PROGRAM V �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE `"�xoe"'" 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) A FACILITY/SITE ME CARE OF ADDRESS INFORMATION / ADDRESS / NEAREST CROSS STREET ✓Butrioli 0 PARTWRSHP 0 STATE-AGENCY 0 C/JRPOUTDN 0 LockiioENLY 0 FEDERAL-AGENCY IO 0 INDNIDWL 0 00UNIY-AGENCY CITY NAME J 1 STATE ZIP CODE SITE PHONE N.WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓BO%dINOIAN EPA ID N RESERVATION or #of TAMP° ❑ 1 GAS STATION ❑ 3 FARM ❑ 5OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE it 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 indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE CFADDHESS INFORMATION MAILING or STREET ADDRESS A/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE AOORBBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 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# JURISDICTION It AGENCY# FACILITY ID# #of TANKS at SITE E / 13151 1 1 101 CURRENT LOCAL!GENC Y FACILl ID# APPROVED BY NAME PHONE If WITH AREA CODE PERMIT NUMBER / PERMIT APPROVAL DATE PERMIT EXPIRATION DATE .1 LOCATION CODE SUPE RICT CODE BUSINESS N DATE FILEDpS❑ /O / CHECKAMOUNT MSURCHARGE AMOUNT FEE CODE RECEIPT 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. C , FORM A(3-2-88) 1t\ r..►� LOCAL AGENCY COPY �