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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM A': m UNDERGROUND STORAGE TANK PROGRAM =" � o SITE I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION d, C COMPLETE THIS FORM FOR EACH FACT ITY/SITE [MARKONLY ❑ 1 NEW PERMIT ❑ 3RENEWAL PERMIT jpJI OF INFORMATION E:] 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 10 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION eI _5ii 2 DO ADDRESS NEAREST CROSS STREET ✓SoxmiMirate D PARTNERSHIP D STATE AGENCY ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEOEAAL AGENCY V V 1 V AL D CO iV AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE k CA g537(o TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PRI ✓Box it INDIAN EPA ID If p of TANK'p ❑ I GAS STATION ❑ 3 FARM HEA RESERVATION or TRUST LANDS I V❑ A 1 AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE w 1 uR-N NIGHTS: NAME(LAST.FIRST) P ON WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHON #WITH AREP CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME n' 1y1L. ) CARE OF ADDRESS INFORMATION Q `V N V S1� MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY O��_w , ( ^ ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY `v, (/ IVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE HONE p WITH AREA CODE CA- SIS `2 1 III. TANK OWNER IAVORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicale D PARTNERSHIP Cl STATE-AGENCY D CORPORATION D LOCAL AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE If 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. ❑ I. 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID# It of TANKS BI SITE CURRENT LOCA L�IGENCY FACILITY IDN APPROVED B NAPE PHONE M WITH AREA CODE W eZ 010o] PERMIT NUMBER PERMIT APPROVAL AT I IIIIERMIT E#01RATION DATE ECHECK# CENSUS TRACT N SUPERVI R-DISTRICT CODE BUSINESS PLAN FILED DATE FILE YES NO PERMITAMOUNT 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. V V ORM A(3-2-88) j/ DATA PROCESSING COPY �/