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STATE OF CALIFORA WATER RESOURCES CONTROL BOARD FORM 'A': "' l/ UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE Ic MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ENTL LOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE Cn fJ1 I. FACILITY/SITE INFORMATION & ADDRESS-/(MUST BE COMPLETED) FACILITY/SITE AME CARE OF ADDRESS INFORMATION ADDRESS /q� r NEAREST CROSS STREET ✓I wr 0' ❑ LOGk-A EN ❑ FSTATE EDEPAGENLY ❑ CNDAWALBN ❑ LOUNNAENGY ❑ FE�ER4L AGENCY /Yw ❑ INOIVIWAI ❑ PAUNiKAGENp CITY NAME STATE ZIP CODE SITE PHONE M.WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 CESSOR ✓Box II INDIAN EPA ID p RESERVATION or #of TANK's F] I GAS STATION El3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If 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 indicate 0 PARTNERSHIP 0 STATE-AGENCY Cl CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,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 Cl STATE AGENCY 0 CORPORATION 0 LOCAL AGENCY ❑ FEDERALAGENCY 0 INDIVIDUAL 0 COUNT)(AGENCY CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS SITE 11 ,6101ol I / CURRENT LOCAL AGENCYPACILITY IQ'YA APPROVED BY NAME PHONE M WITH A I//SU!✓_y_v,1�A PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA7 CODE CENSUS TPACT Y� SUPERVISOR-DISTR T CODE BUSINESS PLAN FILED ❑ DATE FILE 'l ^-� 2 YES NO ,� V CHECK Y PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 11 BY: �5' r THIS FORM BUST BE ACCOMPANIED BY AT LEA f)OR MORE TANK PERMIT FORM 'B'APPLICATION(S)loESS THIS IS A CHANGE OF SITE INFORMATION ONLYFORM A(3-2-BB) c DATA PROCESSING COPY