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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION EVPERMANENTLY Ol 04 DSITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O � I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) r FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓ oirdicale 0 PARTNERSHIP 0 STATE AGENCY /T1 /I CORPORATION 0 LOCAL AGENCY 0 FEDERAL AGENCY V/ IR ❑ INDIVIDUAL 0 COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE k,WITH AREA CODE L-10CA �� o �ao -b TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 Pfl0 SSOR ✓Box ifVATIOINDIAN EPA ID k N or #of TANK's ❑ 1 GAS STATION E] 3 FARM OTHER RESERTRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAY : NAME(LAST.FIRST) HONE k WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE k WITH AREA OODE a01 qyi- a NIGHTS. NAME(LAST, I S PH E#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE S II. PROPERTY OWNER INFO ATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓box tolndoate ❑ PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k.WITH AREA CODE III. TANK OWNER INFORMATION & AD ESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY 0 CORPORATION 0 LOCAL AGENCY ❑ FEDERALAGENCY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRES CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE US\LIRFOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJU111K, AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE = = = 0, 02, � 331 0 Ic'71I CURRENT LOCAL AGENppY FACILITY ID# APPROVED 8Y NAME PHONE#WITH AREA CODE Di df PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIONCODE CENSUS TRACT# SUPERVISOR-D� RI�DE BUSINES,PUN FILED NO ❑ D�E ILED uq'/y/j� D1 z CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# � THIS FORM MUST BE ACCOMPANIED BY AT LEAST IfORE TANK PERMIT FORM 'B'APPLICATION(S), UNLEfIS IS A CHANGE OF SITE INFORMATION ONLY. i�D � DATA PROCESSING COPY Ate'