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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD • I FORM 'A': 1� UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLI ON COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIO 7 PERMANE Y ITE IV ONE ITEM ❑2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ S TEMPORARY SITE CLO RE an cr, I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) V FACILITY/SITE NAME CARE OF ADDRESS INFORMAT N ADDRESS NEAREST CROSS STREET ✓emmPao, ❑ P 11STATE.AGDO ❑ CORPMTON El AGENCT ❑ RPBIAL+GO CY ❑ IMWO AL 1:1N51CY CITY NAME l STATEO E SITE P NE N,WITH AREA CODE CA TYPE OF USINESS: ❑ 2 DISTRIBUTOR ❑d PROCESSOR ✓8ox'rf INDIAN EPA ID a I GAS STATION ❑ 3 FARM ❑5 OTHER TAUSTVLANDS ATION« ❑ tl of TANK'. IS SI AT THIS SITE EMERGENCY CONTACT PERSON(PRI RY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & DDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION C LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl 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 mclicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY C INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE B,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED R BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR ,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY$ JURISDICTION# AGENCY N, FACILITY ID N N of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBERd PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT aSUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 8 YES E] NOD a V761 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT♦ BY: 11,, THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESTH SIS IS A CHANGE OF SITE INFORMATION ON(Lr�Y UAV 9 DATA PROCESSING COPY 1-1,