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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : I o COMPLETE THIS FORM FOR EACH ACILITY/SITE FMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE C" 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) w FACILITY/SITE NAM —�� TC CARE OF ADDRESS INFORMATION ADDRES NEAREST CROSS STREET ✓Ombim4xali, ❑ PAATNBNNP ❑ STATE-AGENCY / ❑ COFOMTION ❑ LOCALAGDO ❑ FM ML AGENCY ❑ INDNI M ❑ CW0YAGENCY CITY NAM STATE ZIP CODE SITE PHONE N.WITH AREA CODE 1D l CA TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a RESERVATION or M of TANK'# ❑ 1 GAS STATION ❑ 3 FARM ❑.5-ETHER TRUST LANDS ❑ ATTHISSITE 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 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 indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LDCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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: I. ❑ if. ❑ 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 R AGENCY# FACILITY ID R K o1 TANKS N SITE - It FACI Y 5 I I I I/ CURRENT LOCAL AGENCY FACILITY 10 N APPROV PHONE N WITH AREA CODE NUMBER IT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS 2TRACT M SUP VISOR-DISTRICT CODE BUSINESS PLAN FILED D LED YES E] NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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) \ �j 4\0t \L ,C_i DATA PROCESSING COPY .,,'i