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STATE OF CALIFORNO WATER RESOURCES CONTR OARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE j FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o `p COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PE Y C SED SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITDE NAME CARE OF ADDRESS INFORMATION h/I� NEAREST CROSS STREET ✓BarbinOrak ❑ PARTNERSHIP ❑ STATE AGENLY ADDRESS ❑ COPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENLY ❑ INDIVIDUAL ❑ couxnAGB+c+ STATE ZIP CODE SITE PHONE N,WITH AREA CODE CITY NAME �1_� CA S20S 31 Cf 7� TYPE OF BUSINESS: ❑ p pISTR18lII0R ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N N of TANK'N RESERVATION or ❑ AT THIS SITE ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER 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 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,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 indicale ❑ PARTNERSHIP ❑ STATEAGENCY C 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 or STREET ADDRESS ✓Box to indicale ❑ PARTNERSHIP ElSTATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS ❑ HECK ONE(1)BOX INDICATING WHICH AROYL ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. pin II. FCIII.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY I� ITTI I COUNTY41 JURISDICTION � AGENICYIN FACILITY ID If N of TANKS at SITE •, 3 z CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ❑ ATE FILED �� • L5— YES NO E] PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If LIMMIMMIMMMMII THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS TRIS IS A CHANGE OF SITE INFORMATION ONLY. L FORM A(3-2-88) "