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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 5�" 'hF v' A FORM `A': UNDERGROUND STORAGE TANK PROGRAM I �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH AICILITY/SITE �"'F�^"�" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANEN SED SITE IV ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACJLITY/SITE NAME - CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ° ✓Bwbin#cAle ❑ PNRNOWIP ❑ STATE-AGENCY w ODUON O �AO� 11 FEDERAL-AGENCY❑ WDY CY CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE r G k: CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PRQQEMR ✓Box A INDIAN EPA ID # RESERVATION or #of TANK's ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ ATTHISSITE EMERGENCY CONTACT PERS N(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST.FI HSI) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMAT N & 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#,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRE — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. ❑ 11. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR , NO TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY pJURISDICTION R AGENCY R FACILITY ID# #of TANKS at SITE F - = d � E010 CURRENT LOCAL AGENCY FACILITY ID tlAPPROV D BY NAME PHONE#WITH AREA CODE PERMIT NUM FI PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAT N C DE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED YES NO ❑ GMECKtl PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: 1 THIS FORM MUST BE ACCOMPANIED BY AT LPA°T(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S). UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. (�I FORM A(3-2-88) �{„' p DATA PROCESSING COPY NNNJJJ�� `�j �'1��' ___ - /