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STATE OF CALIFORNIA' WATER RESOURCESCONTRd`rbOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �e SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACI /SITE MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME R /� CARE OF ADDRESS INFORMATION C Y 'r/ ADDRESS �� // ( NEARESTCROSS STREET ✓BDvbYidrale Cl LOC44411P 0 FEDD14AW `( F.A`�! ❑ CAIRPOIuiNN1 ❑ PMTN A IP ❑ STATE �GEN(.Y U ❑ NDVIWN ❑ WI,WfYAcacY CITU NAME STATE CA ZZ 21P CDDFr� SITE OPHONWITH CODE 7-71c TYPE OF BUSINESS: ❑p DISTNEPA IDM L/•'BUTOfl ❑<PROCESSOR RESERVATION or F W TS SI ❑ 1 GAS STATION F-13 FARM ❑ 5 OTHER 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 Y WITH AREA CODE NIGHTS: NAME(AST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE Y.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. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY ID N M of TANKS K SITE oa CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE P WITH AREA CODE VIA C A Kl"'5I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA N/�ODE CEN8U8 TIIACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED � 11 L Z lj 3 YES NO CHECK P PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT P BY A I 11 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 ONLI FORM �� WWI y