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STATE OF • . CALIFORNIV WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION14 ° I COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT [015 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) I~► FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓SOF Io vdiI 0 PAWNERSHIP Cl STATE AGENCY "A 0 CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY 0 INDIVIDUAL 0 COUNTY AGENCY CITY NAME STATE ZIP C DE� SITE PHONE#.WITH AREA CODE / TYPE OF BUSINESS ❑ p pl TRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # It of TANK's ❑ I GAS STATION 3 FARM ❑ 5 OTHER TTRUSTVATION LANDS or 1:1AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(IAST,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 0 PARTNERSHIP 0 STATEAGENCY 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #at TANKS at SITE v4 CURRENT LOCAL A ENCY FACILITY ID#�� LCODEBUSINESS PHONE#WITH AREA CODE PERMIT NUMBER (/�,,r(/'C/•'J�_ PERMIT APPROVAL DATEXPIRATION DATE LOC 1 CODE CENSUS R N_ SUPERVI ISTRICT SN FOILED NO ❑ DATE FJLEDCHECK M PERMITT AMOUNT SURCHARGE AMOUNT RECEIPT# ( BY: am 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(3-2-88) r DATA PROCESSING COPY