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STATE OF CALIFORN WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM "� "a Z SITE �1 / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o `,P X COMPLETE THIS FORM FOR EACH FACILITY/SITE 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE W MARK ONLY ❑ C:)ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE W I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATI FACILITY/SITE NAME PS T NEAREST CR STREET ✓9oxtaiMiate ❑ PARTNERSHIP ❑ STATE AGENCY ADDRESS 1/T/ i Cl CORPORATION D LOCAL �ITNERAL AGENCY GI„ I ' I �n IJ n D INDIVIDUAL ❑ COON AGEN r 1 Ih C L� ` l/r STATE ZIR,CQDE SITE PHONE N.WITH OE CITY NAME I CL ("JI (✓� TYPE OF BUSINESS: ❑ 2 DIST TOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA DA N o1 TANK's RESERVATION or ❑ AT THIS SITE bV ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) GAYS: NAME(LAST FIRST) ITH AREA CODE DAYS. NAME(LAST.FIRST) PHO ITH AREA CODE NIGHTS'. NAME(LAST.FIRST PHONE N WITH AREA CODE NIGHTS: NAMT) PHONE N WITH AREA CODE E(LAST,F II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME 1�T CARE OF ADDRESS IpW�F�1ATIPN �22 MAILINGo EET ADDRESS ✓Box to indicate(\ D PARTNERSHIP ST AGENCY Yl �1 �� D CORPORATION D LOCAL-AGENCY DERAL-AGENCY ` cc D INDIVIDUAL D COUNT'-AGENCY CITY NAM Wim\ STATE ZIP ODE I PMONEIp.WITH CODE� III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION w NAME n G MAILING or STREET ADDRESS El CORPORATION Clox to indicate D PARTNERSHIP D STATE-AGENCY CORPORATION DLOCAL-AGENCY FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY STATE ZIP CODE PHONE P.WITH AREA CODE CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION � AGENCY p FACILITY ID If p of TANKS at SITE FMEM[mFo-T= FACILITY APPROVED BY NAME PHONE#WITH AREA CODE CURRENT LOCAL AGENCY / D# "\ PERMIT NUMBER PERMIT APPRROOVAALL DATE PERMIT EXPIRATION DATE LOCATIq CENSUS TRAC SUPERVISOR-D S RI T CODE BUSINESS PLAN FILED IL YES E, NO ❑ DA F' j CNECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# OL)BY: [sV�JI THIS FORM MUST BE ACCOMPANIED BY AT LEASTORE TANK PERMIT FORM `B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) DATA PROCESSING COPY