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STATE OF CALIFORM WATER RESOURCES CONTRO�BOARD J. FORM A: UNDERGROUND STORAGE TANK PROGRAM Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 140 COMPLETE THIS FORM FOR EACHy CILITY/SITE MARK ONLY ❑ i NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W FACILITY/ NAMECARE OF ADDRESS INFORMATION jo ADDRESS �T71)'jj VIII NEAREST CROSS STREET ✓ b idi le 0 PNRNERSHP 0 STATE-AGFNGY 3 Q pOMON 0 LOCAL 4GDO 0 FSIER4l AaM(Y V N)ND.AI 0 comr/-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA 33(0 TYPE OF BUSINESS: 2 IS1NtA1TOR 4 PROCESSOR ✓Box I INDIAN EPA ID * IN TANK'* RESE❑ ❑ 5 OTHER TRUSTVATION LANOS of ❑ AT THIS SRE ❑ 1 GASSTATION 43FARM ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE*WITH AREA CODE NIGHTS: NAME( T,FIRST) PHONE N WITH AREA CDDE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) N Jm Y/ CARE OF ADDRESS INFORMATION MAILING w STREET ADDRESS ✓ a to indicate 0 PARTNERSHIP 0 STATE-AGENCY NY CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY D INDIVIDUAL 0 COUNTY-AGENCY CITY NA STATE ZIP CODE PHONE*,WITH AREA CODE �57 III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Box to indicate D PARTNERSHIP 0 STATE-AGENCY D CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE*,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ II. 111. El THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION B AGENCY R FACILITY ID 0 N of TANKS at SITE 4O � CURRENT LOCANCY�E�103v APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBEERPERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATI CODE CENSUS TRACT* BUPERYISOR-DISTRICT CODE BUSINESS PLANFILED DA FILED a3. YES ❑ NO �— CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY � THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. -ORM A(3-2SS) �. DATA PROCESSING COPY ��