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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAMo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C COMPLETE THIS FORM FOR EACH FACILITY/SITE `',�r�N`" I Its MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE PV Cm ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Cn I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION nI f_ ADDRESS NEAREST CROSS STREET ✓Eon to indicate 0 PARTNERSHIP D SD0`E.AGENCY ❑ CORPORATION 0 LGM AGENCY 0 FEDERAL AGENCY A ❑ INOMODAL 0 GOUNIY 11119 CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID a ESEE] I GASSTATION [:] 3 FARM ❑ 5 OTHER TRUSTY LANDS ATION or ❑ AT THIS SITE 2 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 RAST,FIRST( PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE H WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS Be.✓ toinoicate D PARTNERSHIP D STATEAGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERALAGENCY ❑ INDIVIDUAL D COUNTY AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -,/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCALAGENCY0 FEDERALAGENCY D 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 WINCH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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 N JURISDICTION M AGENCY M FACILITY IDR N of TANKS at SITE I h3 O CURB NT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE E C) PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHE ATION CODE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL D �k3� �7 YES ❑ NOCK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS 15 A CHANGE OF SITE INFORMATION ONLY FORM Af3-2- B) - - - //// 'MIPs DATA PROCESSING COPY x.B1