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IGS STA ET OAF CALIFORN WATER RESOURCES CONTROL" BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION = �. COMPLETE THIS FORM FOR EACH FA ITY/SITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) OD fADILITV/SITEN E CARE OF ADDRESS INFORMATION I ADDRESS NEAREST CROSS STREET ✓BOF toIMICeIe ❑ PARTNERSHIP ❑ STATE AGENCY 020 ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENGY ❑ INDIVIDUAL ❑ COUNP(AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE file/7 le CCS CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓8ox it INDIAN EPA ID # E] I GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTVLANDS ATION or ❑ Aof HIS SITE AT THIS STE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Ci- NIGHTS: NAME(LAS FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION SG!~ a S .7- MAILING or STREET ADDRESS ✓Bax W md,,,aoe ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S !nom MAILING or STREET ADDRESS ✓Box lointlicale ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(f)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. IL ❑ 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# F If of TANKS at SITE E a o I tv lo ,GWRENT LOCAL AGENCY FACILITY 10# ) APPROVED BY NAME _ _ PHONE 0 WITH AREA CODE LORMA PERMIT APPROVA DATE PERMIT EXPIRATION DATE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT# BY:ACCOMPANIED BY AT LEAST�R MORE TANK PERMIT FORM 'B'APPLICATION(S), U THIS IS A CHANGE OF SITE INFORMATION ONLY. DATA PROCESSING COPY \\\I�-