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STATE OF CALiFORNO WATER RESOURCES CONTRO BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM x`�m _.�., SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION '0FCR COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER CL ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS ,� // f N REST CROSS STREET' ✓Box toi&4w ❑ PARTNEHStiIP ❑ STATE -AGENCY ON ❑ COJNTY4GEN ❑FEDERAL AGENCY viDuu ❑ cauNTY.AGENcr CITY NAME / i TYPE I ❑ 0GAS5TATI N ❑ 3 RBUSINESS: 2 TMIBUTOR E]4 PRpCR R RESERVATION TRUSTANDS o ❑ EMERGENCY CONTACT PERSON (PRIMARY) DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE rE'S �, ( u ., ,..,r... .-.e c vmo K PHONE It WITH AREA CODE II. PROPERTY OWNER INFORMATI & ADDRESS - NAME MAILING or STREET ADDRESS CITY NAME III. TANK OWNER INFORMATION & ADDRESS - (M NAME MAILING or STREET ADDRESS CITY NAME STATE ZIP ODE SITE PHONE It. WITH AREA CODE EPA ID # R of TANK'S AT THIS SITE EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE ,NIG TS- NAME (LAST, FIRST) PHONE # WITH AREA CODE UST BE COMPLETED CARE OF ADDRESS INFORMATION Box to indicate ❑ PARTNERSHIP CORPORATION ❑ LOCAL -AGENCY STATE I ZIP CODE BE COMPLETED) CARE OF ADDRESS INFORMATION Box to indicate ❑ PARTNERSHIP CORPORATION ❑ LOCAL -AGENCY STATE \ I ZIP CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADMISS SHOULD BE USED FOR BOTH LEGAL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF APPLICANT'S NAME (PRINTED 8 SIGNATURE) . wwa. .v+irui+v I IEC Y%ul V ❑ STATE -AGENCY ❑ FEDERAL -AGENCY PHONE it, WITH AREA CODE Cl STATE-AGFNCY ❑ FEDERAL -AGENCY PHONE #, WITH AREA CODE AND BILLING: I. ❑ II- ❑ 111. ❑ "NOWLEDGE, 1S TRUE AND CORRECT.