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or�.. STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD "' "" FORM 'A': UNDERGROUND STORAGE TANK PROGRAM a SITE FACILITY/SITE INFORMATION and/or PERMIT APPLICATION � a � COMPLETE THISFORM R EACH F CILITY/SITE "" O O C MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE F� ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ,5 Ma 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N FACILITY/SITE NAME� q CARE OF ADDRESS INFORMATION � r ADIXiESS NEAREST CROSS STREET ✓BN W.&W D PAKNDGW D STATE AGENV O' `� 11 NEAREST ❑ LOCALAGDILY D FEDEANAGDO 6 J D mmuk D CDOmAmay CITY NAME /__ - STATE ZIP CODE SITE PHONE ,WITH AREA CODE `�cJ CA sao TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑d SSOR ✓Box it INDIAN EPA ID N RESERVATION or �( Q I of TANW* ❑ I GASSTATION ❑ B FARM OTHER TRUST LANDS ❑ 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 II. PROPERTY OWNER INFORMATI & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Wicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY D INDIVIDUAL D 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 10,M.ate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D 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 OTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,A 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 ID R N of TANKS at SITE ® = = o © o / CURRENT 7AL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE E CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED GpATE 1 YES � NO p , PEWl_fWUOUIIrf SURCHARGE AMOUNT FEE CODE RECEIPTN f 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. f/ WM A(7288) UL/ DATA PROCESSING COPY �.