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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ""' FORM A: UNDERGROUND STORAGE TANK PROGRAM #�• SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° ; o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT L�T5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S 000 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) p�1. FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 1 ti� ADDRESS NEAREST CROSS STREET ✓Dw WIdore [I PARTNERSHIP C STATE AGENCY ❑ CORPORATION C LOCAL AGENCY D FEDERAL AGENCY ❑ INDIVIDUAL D C0010 AGENCY CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE CA TYPE of BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROCESSOR '/Box it INDIAN EPA ID a S of TANK'B F-1I GAS STATION F__] 3 FARM ❑ 5 OTHER TRUSTVATION LANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE K 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 I/Box to inftrile D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY C FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to'mdicate D PARTNERSHIP D STATE-AGENCY C CORPORATION C LOCALAGENCYD FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. ❑ IL ❑ 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 k JURISDICTION M AGENCY R FACILITY ID N A of TANKS at SITE v v G ; CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE c O PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS CENSUSSTTRACT T[`�0 SUPERVISOR-DISTRICT CODE BUSINESSPUN FILED NO ❑ZFORMATION CHECNN W PERMIT AMOUNT SURCHARGE AMOUNT `/ FEE CODE RECEIPT THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS, CHONLY. FORM A DATA PROCESSING COPY