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STATE OF CALIFORNI)i WATER RESOURCESCONTR6rtOARD Vie '"" FORM `A': UNDERGROUND STORAGE TANK PROGRAM ="°ter SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE �°"'�"-"—" MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 2r7 PERMANENTLY CLOSED SITE I"+ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 W I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE NAME ,I CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓EorbnENSN ❑ ?WNBISHIP ElSTATEAGENCY h n ❑ AATKKi ❑ LOGI-AGENCY ElFEDERAGBKY EEK' AL ❑ WUNIY-AGENCY CITY NAME STATE I-ZIP CODE SITE PHONE N.WITH AREA CODE Y1 CA TYPE OF BUSINESS: DISTRIBUTOR ❑ 4 PROCESSOR ✓BO%Yi11NDIdr AN EPA IDN _ It W TANICt JJ � ❑ 1 GAS STATION ❑ 3 FARM E] 5 OTHER TRUSRLANDS ❑ AT THIS SITE Ov 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( ST FIRST) PHONE N WITH AREA CODE NIGHT NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Ru ( < - MAILING orSTRE ADDRESS ✓Box to,d icaia ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ PORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY L,( INDIVIDUAL ❑ COUNTY-AGENCY GIIV NAME STATy1 ZIPCODEq szo PHO WITH AREACODE �� 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) ^( 4 NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS v/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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: I. ❑ II. 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 R JURISDICTION N AGENCY N FACILITY ID It B of TANKS at SITE E 2 UU CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE tSS v PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE FCHECK* ODE CENSUS TRA�CT N\ SUPERVISOR-DISTflICT CODE BUSINESS PLAN FILED DATE FILED a 3 DV y YES � NO _`O •V� PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-II8) _ 1%.04 DATA PROCESSING COPY `IN• J