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01� . STATE OF CALIFORNIA WATER RESOURCES CONTROLSOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM = ' SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ? " C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEWPERMIT 7 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑a AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILI IY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bw ❑ PNENERSHP ❑ STATE AGENCY T RATION ❑ LOCAL AGENCY' ❑ FEDERLNENC! 1 ciaoE ❑ IIIGIouk ❑ CUNTYMENCY CITY NAME STATE ZIP CODE ST TE PHONE M.WITH AREACODE M Ar►V-T CA 953 ��e TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 1 N of TANI(' PROCESSOR ✓Box H INDIAN EPA ID a ❑ RESE I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVATION LANDS a ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS. NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(CAST,FIRST) PHONE K WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to ioasNle ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to ion.cale Cl PARTNERSHIP ❑ STATE-AGENCY ❑ 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(T)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III.❑ 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 COUNTY11 JURISDICTION B AGENCY B FACILITY ID R K of TANKS At SITE " 3 I I SLK CURRENT LOCAL AGENCY FACILITY ID 1 APPROVED BY NAME PHONE F WITH AREA CODE MU rvT1Z PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT F SUPERVISOR-DISTRICT COOP BUSINESS PLAN FILED DATE FILED YES NOE] �� CNECKY PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT♦ my C\ THIS FORM MUST BE ACCOMPANIED BY AT LEAST 1^OR MORE TANK PERMIT FORM '8' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 1"1 \\\\FORM A(3-2-M) ' 1