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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A'N UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR!A�y FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ir 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE - ,rd I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION St N Afftcic ADDRESS NEAREST CROSS STREET ✓ bx4+sN ❑ PARTNEREHP ❑ STAIE�AGENCY 56 rc� ETON ❑ LODL 4DO ❑ FEDERAL-AglR Lowe, ❑ IALIMDk ❑ CMMAGINCY CITY NA STATE IP CODE SITE PHONE M,WITH AREA CODE ack CA S - 6 -5 TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID M RESERVATION or /� ATT HIS SI ❑ I GAS STATION ❑ 3 FARM 50THEfl TRUST LANDS ❑ (//<N ATTHISSITE 011 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAXLAST.(IRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH A A CODE NIGHT NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ea MAILING or STREETAD ✓ xlo intliCele ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMEST E C DE PHONE N.WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION a MAILING or STREET ADDRESS ✓Box lomdreale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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 E JURISDICTION R AGENCY N FACILITY ID R R of TANKS at SITE O 10 1 / 1/= 10 1 o 10 10 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTNICT CODE BUSINESS PLAN FILED DA FILED t YES NO 2 CHECK♦ PERMIT AMOUNT SURCHAROE AMOUNT FEE CODE RECEIPT N BY: // THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ORM A(3-2-88)