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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z ]- 1O COMPLETE THIS FORM FOR EACH F ILITY/SITE `'<,.aR„•" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SIT ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N F ITY/SITE NAME CARE OF ADDRESS INFORMATION w 1 E S ADDRESS NEAREST CROSS STREET ✓Bwwv w ❑ PARTNERSHIP ❑ STATE AGENCY S ❑ GOPORANON ❑ LOCALAGENCY ❑ FEDERAL-AGENCY Cl IWNIWAL ❑ COUNTY-AGENCY CITY NA STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID p ❑ 7 GAS STATIONSEVATION❑ 3 FARM ❑5 OTHER TRUST LANDS or ElN of TAMP# AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N 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 A II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to mclicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE i 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to mc,cate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,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. ❑ 11. ❑ 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) DATE LOCAL AGENCY USE ONLY IAB1ak COUNTY# JURISDICTION It AGENCY# FACILITY ID N Al of TANKS at SITE i m 1 1 112 1 a 10 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPER ISOR-D TRICT CODE BUSINESS PLAN FILED DATE FILED q BO YES E] NO [—] CHECK# PERMIT AMOUNT SUACHARG#AMOUNT FEE CODE RECEIPT# BY: THISFORM MUSTBEACCOMPANIED BYAT LEASTJI)OR MORETANK PERMIT FORM '11'APPLICATION(S), UNLESS THIS ISACHANGE OFSITE INFORMATION,OKCY. FORM A(3-2-88) / `� DATA PROCESSING COPY �, ,/