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STATE OF CALIFORNIt WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM mo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE "'� MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PE.9-M&EqTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) FACIUTY/SITE NAME „A}j" CARE OF ADDRESS INFORMATION �FI � 4 6 p {F I ADDRESS / ^ ,. NEAREST CROSS STREET ✓Bmlikkat ❑ PMIIER9YP ❑ STATE AGENCY ❑ COfOUTDN ❑ UCALAGENN ❑ RDENLLAGFNLY ❑ RDNDuu ❑ OXAM-AGENCY CITY NAME �/, —Z,.Jam_. STATE ZIP COIi�� SITE PHO E M,WITH AREA CODE-�t gzk TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑1 PROCESSOR�{✓Box R INDIAN EPA ID N G/j' Z��/7 y��--(7/ ..J ❑ I GAS STATION 3FARM 5OTHER RESERVATION AT ATTHISSITEL/ ❑ ❑ TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIG TS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE N 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 N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING m STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ H. ❑ 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION Y AGENCY N FACILITY ID N N of TANKS at SITE " I I I y �) I I /" I I I I t�) CURRENT LOCAL AGENCY FACILITY ID E APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N BUPERYIBO"IBTRICT CODE BUSINESS PSN❑ FILED NO ❑ DATE FILM-5 CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: o� THIS FORM MUST BE ACCOMPANIED BY AT LEASjj)•OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY,.._ / FORMA(3-2-68)