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STATE OF CALIFORI WATER RESOURCES CONTROL BOARD A FORM 'A': _ tea Z UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o COMPLETE THIS FORM FOR EACH FACILITY/SITE `^11soaWa MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 1 TLV CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CD I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) U'I FACILITY/SITE NAME u/ CARE OF ADDRESS INFORMATION CA_L, (_ ADDRESS 2 NEAREST CROSS STREET I/Bre lniMwRV Cl PARTNERSHIP ❑ STATE AGENCY lA 5 S/7 ❑ COBPoRITON ❑ LOCAL AGENCY ❑ FEDERAL AGENCY ❑ INDIODU0. ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE C off/ CA cls Zy° ° - 33y- �S TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a N RESERVATION Or of TANKY �J F-1I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE !� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST( PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY O CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl 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 ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOA INDICATING WHICH 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY* JURISDICTION N AGENCY N FACILITY 10 a N of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE G� PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE c LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED F U2 2' d 3� U YES NO 4LY. CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY:THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO RM 'B'APPLICATION($), UN THIS IS A CHANGE OF SITE INFORMATIO FORM A(3-2-881 _ FYATA Pni .�......