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I STATE OF CALIFORNI? WATER RESOURCES CONTRBOARD FORM 'A': SITE UNDERGROUND STORAGE TANK PROGRAM V'+ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION mem ! !�I � COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY El 1 NEW PERMIT 3 RENEWAL PERMIT ONE ITEM []5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE 2 INTERIM PERMIT 4 AMENDED PERMIT RESS- 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADD / FACIL/I ITY/SITE NAME L� (MUST BE COMPLETED) I wO�D If "�'(,��(//// / CARE OF ADDRESS INFORMATION ADDRESS b CJ NEAREST CROSS STREET ✓Rar roibrzb 0 PARTNEAVWDO CITU NAME 0 LOCALAOD OBNPORATIDN ❑ STATE INp11WA1 EN 0 FEDERAL AGI 00 STATE � OOUNII''AC+ENLY '^ ZIP CODE SITE PHONE e,WITH AREA CODE W TYPE OF BUSINESS CA W E]2 DISTRIBUTOR4 PROCESSOR ✓Box it INDIAN EPA ID p 1 GAS STATION []3 FARM 5 OTHER RESERVATION or El Of TANK's p TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON(SECONDARY) PHONE Y WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRSTI PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF AUDRESS INFORMATION MAILING or STREET ADDRESS ✓Boa to lntlicale 0 PARTNERSHIP 0 CORPORATION ❑ LOCAL-AGENCY STATE-AGENCY CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY FEDERAL-AGENCY STATE IZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAIUI ar STREET ADDRESS ✓Boa to Andicale Cl PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CTY NAME STATE ZIP CODE PHONE p,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: I. II. 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 a JURISDICTION p AGENCY p FACILITY ID S At of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE p WITH AREA CODE li✓o0/D b PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT p SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED CHECK N YES PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a �� Bya/)�� I THIS FORM MUST BE ACCOMPANIED BY AT LE"O'r1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONL .