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STATE OF CALIFORA WATER RESOURCES CONTROL BOARD r i eEn` xtif J FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� o COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 1. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) Zlh W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bo.lo vdiwR C PARTNERSHIP- C STATEAGENCY INDIVIDUAL C LOCAL OODNVABG.CEN� C FEDERAL AGENCY C CIN NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA 5-.20S" TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p RESERVATION or X of TANK'S ❑ 1 GASSTATION V3FARM ❑ 5OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION i7/ N MAILING ol STREET ADDRESS ✓Box to indicate C PARTNERSHIP C STATE-AGENCY C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY OO C INDIVIDUAL C COUNTY-AGENCY CITU NAME STATE ZIP CODE PHONE AL WITH AREA CODE cC/� nl ,ZOTS Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION C LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL C COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE A,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. ❑ 11. v 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# JURISDICTION If AGENCY# FACILITY ID# If of TANKS BI SITE al-21 = olo0 1 CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Lf CODE CENSUS TRACTI! SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE 3. L3YES NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-BB) DATA PROCESSING COPY