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STATE OF CALIFORNIA WATER RESOURCESCONTROL'BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SIT!7 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT PfCHANGE OF INFORMATION 7 PERMANENT Y CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) FACILITY/SITE NAM CARE OF ADDRESS INFORMATION ADDRESS ^ J NEAREST CROSS STREET ✓ D PARTNERSHIP IXD AGENCYSTATE 11 0011PORPON 11 LOCA-AGENCY ❑ FEDERAL-AGM 11 INDYWAI ❑ NDUNTYAGEN CITY NAME / �. STATE ZIP CODE SITE PHONE N,WITH AREA CODE /�✓/✓wr',nl CA TYPE OF BUSINESS: ❑ 2 DISTRBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a X of TANKY 1 GASSfATION FARM 5 OTHER RESERVATION w ❑ ❑ TRUST IANOS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.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 D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D 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 or STREET ADDRESS ✓Box to irocale D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD SE 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. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY IDE R of TANKS at SITE " 34 =� 6 Oo CU ENT LOCAL AOlNCY ACILITI'ID R APPROVED Y NAAMME ?L� PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PE MIT EXPIRATION DATE LLOCKnORT CENSUS TRACT• SUPERVISOR-OISTRICT CODE BUSINESS PLAN FILED DATE FILEDYES NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: THIS FORM MUST BE ACCOWANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.;^ ` FORRM`M A(3-2-881 • • 7