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STATE OF CALIFORNO WATER RESOURCES CONTFIR BOARD �` °� 'N FORM A: UNDERGROUND STORAGE TANK PROGRAM SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� COMPLETE THIS FORM FOR EACH FACILI ITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 21-5—CHANGE OF INFORMATION ❑ 7 PERMANENT' E ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bm Wddinm ❑ PARTNERSHIP [I STATEAGENCY 0 Cl INONiouuON O COUNTYAGEN ❑ FEDERAL AGENCY CITY NAME �C7 O STATE ZIP CODE SITE PHONE N.WITH AREA CODE TYPE OF BUSINESS'. ❑2 DIST IBIDOR ❑A PROCESSOR ✓Box if INDIAN EPA ID N If of TANICs F-1I GABSTATION F__] 3 FARM ❑ 5 OTHER TRUSTY LANDS or ❑ A THISSITE 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 M 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 ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.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. ❑ it. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS Bf SITE l =] = = [ C)I .2 1 LIt�I Cp ' CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE /-G/C G \� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: W THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-BB)