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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD eeA' FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =`° SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ` , to G COMPLETE THIS FORM FOR EACH FACILITYISlw MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F"+ ONE ITEM ❑p INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE a) 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY ITE NAME CARE OF ADDRESS INFORMATION e � ADDRESS N�g,�EST 0 STREET ✓Bm RNtlule 0 PMTNERWP 0 STATE-A ND C =EST r, '�J O NDcalMWk Cl -ACE OXPiTY � ❑ FEOEwu wExc CITY NAMED STATE Z CO E qITE PHOILE N,WITH AREA CODE CA a o aa9 3 - a�65 TYPE OF BUSINESS. ❑p DISTRIBUTOR ❑ d SSOR ✓Box it INDIAN EPA ID N ESE `�'}�I e ❑ 1 GAS STATION ❑ 3FARM OTHER TRUSTVLANDS W ❑ Yvv,� AT THIS SITE 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(LAST.FIRST) \ PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATI & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to imicale D PARTNERSHIP D STATEAGENCY D CORPORATION 0 LOCAL-AGENCY D FEDERALAGENCY Cl INDIVIDUAL D COUNTY AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to owlicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION Cl LOCAL AGENCY Cl FEDERAL AGENCY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR TN LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AN TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY* JURISDICTION R AGENCY R FACILITY ID R M o1 TANKS at SITE CURRENT LOCAL AGENCY FACILITY 10 F APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT. SUPERVISOR-DISTRICCTT CODE SUSINESSPLANFILED DATE FILED J uYES NO /a 3 \ CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: f\IATON ONLY. TNS FORM MUST BE ACCOMPANIED BY AT LEAST 11)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORM �"