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rroi STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD r FORMA': UNDERGROUND STORAGE TANK PROGRAM Z Sl FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° to G COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) W FACILITY/SITE NAME , CARE OF ADDRESS INFORMATION ADDRESS i0*1 /✓ NEAREST CROSS STREET ✓Eoxb royale ❑ FAAINEASHIP ❑ STAIE-AGENCY ❑ ATION Cl LOCAL AGENCf ❑ FEDERAL AGENCY NIOUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP DE PHONE ,WITHAREACODE CCA ao9 549- � TYPE OF BUSINESS. 2 DISTRIBUTOR ❑ 4 PROCESSOR I/Box if INDIAN EPA ID a� � � � X of TANK's RESERVATION or v`"_f_ AT THIS SITE ❑ 1 GAS STATION FARM ❑ 5 OTHER TRUST LANDS ❑ /v EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE onqao - NIGHT$' NA (LAST,FIRST) PMO E M WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE X WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It 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 A.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. o II. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYIT JURISDICTION M AGENCY R FACILITY ID N K of TANKS at SITE az = = 1010=_ CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CEI CT k UPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO CHECA M PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPTN 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. FORM A(3-2-1111) �� DATA PROCESSING COPY \�I