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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE R _?CILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT _; :RANGE OF INFORMATION 7 P LY CLOSED SITE ONE ITEM ❑Z INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE SOl z I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 10 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION A SS NEAREST CROSS STREET ✓BRb kw 0 PNITWY&v SIAIEAGENLY N I �. O INDVOPLCOWWTDN DD -AACDUNTY GEN CY O RARULu,Er�c CITY NAME STATE ZIP CODE SITE PHONE M.WITH AREA CODE W ( CA TYPE OF BUSINESS' ❑p DISTRIBUTOR ❑4 PROCESSOR E EARVAINDIAN EPA ID M A of TANK'N ❑ I GASSTATION ❑ 3 FARM ❑5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST FIRST) PHONE x WITH AREA CODE DAYS NAME ILAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRSTI PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓80x to inOicAM 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to ind"Ie 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENO D FEDERAL-AGENCY 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 WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N A IIGENNCCYIIIJI FACILITY ID N 'yI R DI TANKS at SITE ( I O 1 C V CURRENT/sp AGENCY FACILITY IDN LOCAL APPROVF,"7 NAME PHONE R WITH AREA CODE PERMIT NUMB" T PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LHECKS ON CODE CENSUS TRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DA F LED YES E] NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT P BY: t 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. ✓ *4"