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STATE OF CALIFORNO WATER RESOURCES CONTROL:BOARD �y `^t".A FORM 'A': UNDERGROUND STORAGE TANK PROGRAMo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EAC ACILITY/SITE °9�„_"—`" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ll� 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I" ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 11 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CD (D FACILITY/SITE ME CARE OF ADDRESS INFORMATION L- CJ ADDRESS NEAREST CROSS STREET .✓ irate E) PARTNERSHIP ElSTATE AGENCY CORPORATION ❑ LOCAL AGENCY El FEDERAL AGENCY G / �� Q ❑ INOIVIOUAL ❑ COUNTY AGENCY CITY NAMESTATE Z�FODE SITE PHONE A.WITH AREA CODE G� /07� CA 7`S3� TYPE OF BUSINESS ❑ 2 DI TRIBUTOR ❑ 4 PROCESSOR ✓Box i(INDIAN EPA ID ft ❑ 1 GAB STATION 3 FARM 5 OTHER RESERVATION or 6 of TANK'e � ❑ TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Dox to indicate ❑ PARTNERSHIP E STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY 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 ADDREBS5 Box lon icale ❑ PARTNERSHIP ❑ STATE AGENCY Cl CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,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: I. ❑ 11. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION k AGENCYA, FACILITY ID R R of TANKS at SITE LU E= = I 1 12115 ,A CURRE G NCY FACIL TY APPROVED BY NAME PHONE M WITH AREA CODE UL ),5 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOC ATI NODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE LED YES NO � i CNECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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. FORM A(3-2-88) 0 DATA PROCESSING COPY -!