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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �yE FORM `A': UNDERGROUND STORAGE TANK PROGRAM z' " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Io al COMPLETE THIS FORM FOR EACH FACILITY/SITE `'�"op"-`" MARK ONLY ❑ ) NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1531 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) r V C!1 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION / ADDRESS NEAREST CROSS STREET ✓Ba IOINifdle ❑ PARTNERSHIP ❑ STATE AGENCY ,i — . l ❑ CDAPOItATION ❑ LOCALAGENGY ❑ FEDERAL AGENCY lJ ❑ INDIVIDUAL ❑ CWNIYAGENCY CIN NAME STATE ZIP CODE SITE PHONE a.WITH AREA CODE CA TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA IC a ❑ ❑ ❑ TRUSTVLANDS or ❑ It of TANK'N 1 GAS STATION 3 FARM S OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS s/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,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 APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID It #of TANKS at SITE m = ,5-1 1 1 1 10 CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK* ODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED ��x 3 YES NO .3/ �/ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p 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. FORM A(3-2-88) DATA PROCESSING COPY