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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD Eli ,. FORM IA': UFir}EpC„ROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION en Com- COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT LJ" CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE CD N I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Brn A,W ale ❑ PARTNERSHIP ❑ STATE AGENCY� ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY S. S G 7A�� ❑ INDIVIDUAL ❑ COUNtt-AGENCY CITY NAME STATE ZIP CODE SITE PHONE I,WITH AREA CODE /pr o n CA vs3i� G Zcsi s f9 v�L P TYPE OF BUSINESS: 0 2 DISTRIBUTOR � 4 SSOR ✓Box ii INDIAN EPA ID I X of TANK's RESERVATION or AT THIS SITE ❑ I GAS STATION ❑3 FARM 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE S WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE 8 ,.t rrr C C/ NIGHTS AME(LAST,FIRST) PHONE I WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE M WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRE ✓Be.to Inft.te ❑ NERSMP ❑ STATE AGENCY ❑ CORPORATION LOCAL-AGENCY ❑ FEDERALAGENCY S 6( ❑ 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 S CC "x .7 s•-L MAILING or STREET ADDRESS ✓Box to indicate ❑ PA SHIP Ll STATE AGENCY ❑ CORPORATION CAL AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE I,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADOIR10 SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. Ll if. [:j 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYII JURISDICTION X AGENCYII FACILITY ID X X of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME PHONE I WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT S SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ©s ') 3 �a 3 � YES NO ❑ CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT S BY: THIS FORM MUST BE ACCOMPANIED BY AT LEA fi)OR MORE TANK PERMIT FORM 'B'APPLICATIONS) ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-BB) I 'J �f� DATA PROCESSING COPY