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STATE OF CALIFORNI)r WATER RESOURCES CONTROLNBOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =` SSTFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION t 7 r COMPLETE THIS FORM FOR EACH FA91LITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑'S CHANGE OF INFORMATION 02r7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY(SITE NAME/V� ^, _40CARE OF ADDRESS INFORMATION ADDRESS `C N EST CROSS STREET ✓&ab wiaii, ❑ PMRINEINN ❑ 9AMAG90 1 _ ❑ WIPOPOTON ❑ LOGL.AGDO ❑ ff11E141.MGBILY l o INommk o I omme AGYNC! CITY NAME // -- ,,/ STATE ZIP ODE SITE PHONE N,WITH AREA CODE / D d, CA a o TYPE OF BUSINESS: ❑ 2 D BUTOR ❑ 4 PRDCESSOfl ✓Box 4INDIAN EPA ID N ❑ I GAS STATION FARM ❑5 OTHER TRUST LANDS ESERVATION of ❑ •of TANK'N D AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST,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(I-AST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATI &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to in0icate ❑ PARTNERSHIP ❑ STATE-AGENCY El CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS- (MUSTRE COMPLETED) NAME 61RE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ox to ind,c Ie ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ IN VIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOYB AOOBBBB SHOULD BE USED FOR BOTH LEGAL NOT[*TON AND BILLING: 1. 11. ❑ 111. ❑ 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 R JURISDICTION N AGENCY M FACILITY ID N N of TANKS BI SITE CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE S PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L O CODE CENS7 CTpN SUPERVISOR-DISTRICT CODE BUSINESS PLAN❑FILED NO ❑ DA FILED ED CHECI(N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TAME PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. RM A(3-2-88) ✓(l RiE)