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STATE OF CALIFORA WATER RESOURCES CONAL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �A a COMPLETE THIS FORM FOR EACH FACILITY/SITE `'�!•�a"`" MARK ONLY ❑ 1 NEW RAMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 P D SITE F-J ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ftsr- A ADDRESS NEAREST CROSS STREET Be,✓ Nvdfele ❑ PMTNEFSHP D STATE AGENCY Z 13CORIMTON D LOCN#GRO D I'MER&I-44ENCY ' D INDNDMI, D COUNTY-AOENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS: 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA 10 N RESE❑ 1 GAS STATION ❑3 FARM ❑5 OTHER TRUSTVLANDS ATION 0f ❑ AT THIS S1TE ' EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N 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 or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D 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 indicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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 ORRECT_APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNT JURISDICTION AGE FACILITY N � � #of TANKS al SITE 3 CURRENT LOCAL AG NCY FACILITY I0N33 APPROVED BY NAME PHONE N WITH AREA CODE i 7- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE i LOCATION CODE CENSUS TRACT N SUPERVISOR-0ISTRICT CODE BUSINESS PLAN FILED FILED �Y Z� YES NO —jJ CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N is 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'AFRLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY eV),/J1 FORM A(3-2-M7) . 0.4YA PROCESSING COPY 0