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Six vvot� x'�e STATE OF CALIFORNIx WATER RESOURCES CONTROrBOARD a FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE /FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION v COMPLETE THIS FORM FOR EACH FAC /SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 P/ TLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE (% I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS 2 I {•{BILI JC NEAREST CROSS STREET ✓8a bm&* D PMTNUMP D STATE / l 1L a �l�l� �PsIEK. D mmmDRATNXI D LCM mgmAFNLY ❑ Fmwu.ACErwY ❑ ND ORAi D CCUIIYJ�GENC/ CITY NAME ^ ,,�� L STATE ^A ZIP OD�Fr� SITE PHONE W IT^REA CODE TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ,`❑/ 4 PROCESSOR -./Box tf INDIAN EPA 10 N /�/ N of TCs RESERVATION or ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUST LANDS ❑ AT THIS S 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 INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to,odicala D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY Cl INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to roeicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION k AGENCY N FACILITY ID N R of TANKS H SITE DO CURRENT LOCAL AGENCY FACILIl N APPROVED 8Y NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIO CODE CENSUS TRACT N SUPERVISORAI/BTRICT CODE BUSINESS PLAN FILED DATE FILE p 1 � z- ZStj YES [—] NO ��0 CHECK# 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 IS A CHANGE OF SITE INFORMATION ONLY FORMA(3-2-88) J