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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAMo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION10 -� z COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 W PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERM CLOSED SITE r ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE D -4 FV I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) co FACILITY SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREE ✓ bbCxsk ❑ PAWNER5IN ❑ STATEAGMSo F S� 7 PGPA GN o LOCA Aca� o BEER .AGB ❑ INDNIDIIAI Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA C9, o2 0 TYPE OF BUSINESS ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box d INDIAN EPA ID N ❑ I GAS STATION ❑ 9FARM li?i OTHER TRUST LANDS oVATION r ❑ "" • `�`� AT THIS SITE 274 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,FIRS ) PHdNE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE S II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMES CARE OF ADDRESS INFORMATION soct II MAILING or STREET ADDR ✓ to indicate ❑ PARTNERSHIP 11STATE-AGENCY ORPORATION 13LOCAL-AGENCY ElFEDERAL-AGENCY 1 D INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME /� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS %/Box to indicate ❑ PARTNERSHIP ❑ 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. II. 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 N AGENCY N FACILITY IDN N of TANKS of SITE [m] = = l(0101 / = CURRENT OCAL I�EyCY F/1CILITY}jA APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER /K` `/T/jJ1 PERMIT ROYAL DATE PERMIT EXPIRATION DATE ©© s a LOCATION CODE CENSUS TRAC N SUPE 1 Oq-DISTRICT CODE BUSINESS RAN FILED DATE FILED Q a a YES E3 NO ❑ CNECK N PERMITAMOUNT SURCHARGE AMO NT FEE CODE RECEIPT I I B 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. ' A / FORM A(&2-88) U� \.r DATA PROCESSING COPY � "