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ole, STATE OF CALIFORNIA WATER RESOURCES CONTRA OARD FORM A: UNDERGROUND STORAGE TANK PROGRAM �o SITE �j FACILITY/SITE, INFORMATION and/or PE IT APPLICATION COMPLETE THIS FORM FOR EACHF LITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION P CLOE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE y SED S I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓BmbidM ❑ PANINOWIP ❑ STATEAGBICi . / , ❑ COWOMTION ❑ LOCAL-AGM ❑ RDEML AGBC/ V�/ ❑ ICNIIDAL ❑ OWMAGINCY CITY NAME STATE ZIP CODE /' SITE PHONE#,WITH AR CODE G CA LTS � C o TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box B INDIAN EPA ID a #of TANK'S ❑ 1 GAS STATION 3 FARIA ❑ RESERVATION or ❑ AT THIS SITE ❑ 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE C WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING Or STREET ADDRESS ✓Som o' ate ❑ PARTNERSHIP ❑ STATE-AGENCY /tele ❑ C RATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY h/ [, NDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAIUNG or STREET ADDRESS ✓Box to,.dicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE Y,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. ❑ 11. ❑ 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 R 1 JURISDICTION S AGENCYII FACILITY ID R #of TANKS at SITE " CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L OCATIONODE CENSUS TRACT 4 SUPERVISOR-DISTRICT CODE BUSINESS PLAN❑FILED NO ❑ DATE FILED PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: ✓�S G 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. FORMA(3-2-138)