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STATE OF CALIFORNII WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE /' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; �✓' COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE G I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAW, CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bm bY&'ab 0 PAATNERRNP ❑ STATE AGENCY C1 WIVIDUAL 11 �YAGENY ❑ FEGEMI AGENIX CITY NAME �� STATCA ZIP CO3 Z 0 / ❑ ❑ I/ BITE PHONE N,WITH AREA CODE TYPE OF BUSINESS: 2DISTRIBUTOR 4PROCESSOR Boa it INDIAN EPA 10N VF ('/•/Cf— '� 1 TANK'. RESERVATION w0 0 ❑ 1 GAS STATION E]3 FARM El5 OTHER TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAY j q(LAST, �T�/ —T PHONE I1 WSi A��1DE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST). PHONE/#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 w STREET ADDRESS ✓Boa to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY D 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 o,STREET ADDRESS -/Box tomdicate ❑ PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY Y JURISDICTION IF, AGENCYII FACILITY ID A M of TANKS NI SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT#7 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 11 e9/ J Z/ 3 z L_/ YES NO CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N IIYo THIS FORM MUST BE ACCOWANIED BY AT LEAST T)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),�SS THIS IS A CHANGE OF SITE INFORMATION ONLT�, FORMA(3-2-&B)