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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD _V " FORM `A': UNDERGROUND STORAGE TANK PROGRAM Yr Q SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - COMPLETE THIS FORM FOR EACH FACILITY/SITE �R4P`9"=P y rh ARK ONLY F-11 NEW PERMIT F__] 3 RENEWAL PERMIT CHANGE OF INFORMATION El7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) W tal FACILITY TE NAME CARE OF ADDRESS INFORMATION 4;111111 ADDRESS NEAREST CROSS STREET ✓Box toT4icate El PARTNERSHIP ❑ STATEAGENIN ,••�I ) F' ❑ OOR?ORATION ❑ LOM-AGENCY Cl FE6ERAL AGENCY !/�./ ❑ INONIOUAL ❑ GOUNTY-AG€NGY CITY NAMESTATE ZIP CODE SITE PHONE p,WITH AREA CODE Q CA 919 2Z C3 TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box i1 INDIAN EPA ID 0 #01 TANK's 1 GAS STATION 3 FARM 5 OTHER TRUSTVATION LANDS or AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE q WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. 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 ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY E3 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Q INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE R.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. IIL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLkGANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #o1 TANKS at SITE 9 1 1 E I I I � [ I I i I (-ol EU E I I :Ul CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO I _/,70 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# THIS FORM MUST BE ACCOMPANIED BY AT LEAS OR MORE TANK PERMIT FORM `B`APPLICATION(S), U ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) DATA PROCESSING COPY