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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION G COMPLETE THIS FORM FOR EACH FAC ITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SE TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME cn CARE OF ADDRESS INFORMATION C-Y �L/ 030q ADDRESS NEAREST CROSS STREET ✓Bakixicsle ❑ PARTNERSHIP ❑ STATE A690 I^ \ p ❑ COPORANON ❑ LGCAL AGENCY ❑ FEDERAL AGRO ❑ INDIVIDUAL ❑ ODUNTY.AGENCY CITY NAME STATE ZIP CODE SITE PHONE A.WITH AREA CODE T2Rc ' CA TYPE OF BUSINESS. 2 DISTRIBUTOR 1 PROCESSOR -/Box iI INDIAN EPA ID N _ N of TANKY ❑ 1 GAS STATION ❑3 FARO ❑ ❑ ❑ 5 OTHER RESERVATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(IAST,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 10 in0icate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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 ✓Box to mI icale D PARTNERSHIP D 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: 1. ❑ it. ❑ 111.❑ 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) GATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION R AGENCY* FACILITY ID R S of TANKS at SITE I 1 11 4 1 0 Icy I I 1 1 13_ CURRENT LOCAL AGENCYY F`A/CILLIIW IDN APPROVED BY NAME PHONE N WITH AREA CODE SCSV C.i1V O ECHECK# LKERMIT PERMIT APPROVAL DATE PERMIT EXPIRATION DATE RACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED �q VES NO MOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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. FORM A(3-2-88)