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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD "Ea`""` t"` FORM 'A': UNDERGROUND STORAGE TANK PROGRAM g � . i SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� o COMPLETE THIS FORM FOR EAC ACILITY/SITE �""aa��r MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ANGE OF INFORMATION ❑ 7 PERMANENT TE I IJ ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE � I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION N YI 1NPS ADDRESS VNEAREST CROSS STREET ✓9wloin6mk 0 PARDkRSHIP 0 STATE AGENCY 0 COBPOUNON ❑ LOCALAGDO 0 FEDEPAIAGM 1 I 0 INDIVIDUAL 0 OJUNWAGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AFIEA CODE s (OCA 9913zo 209,_? Fs '326 TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑4PROCESSOR ✓Box if INDIAN EPA ID N RESERVATION or N of TANK'* ❑ I GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS 1:1 JA THIS SITE O EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE Al WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CIT'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 -/Box to Indicate 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 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ 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 R JURISDICTION* AGENCY N FACILITY ID N R of TANKS at SITE SCJ l � CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA C dbE— PERMIT NUMBER I PERMIT APPROVAL DATELCODIE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISBUSINESS PLAN FILED DATE FILEYES ❑ NO gCHECK* PERMIT AMOUNT SURCHARGE AMODE RECEIPT* BY: 4\ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OFSITE INFORMATION ONLY. \ oRM A(3-2-88) �., DATA PROCESSING COPY i