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STATE OF CALIFORIOA WATER RESOURCES CONAL BOARD FORM 'A': SITE UNDERGROUND STORAGE TANK PROGRAM 7 m FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� COMPLETE THIS FORM FOR EACH FACILITY/SITE EMARKNLY ❑ T NEW PERMIT ❑3 RENEWALPERMITEM RANGE OF INFORMATION ❑ 7 PERM Y CLOSED SITE f ❑2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILRY/SITE NAME CC _ CARE OF ADDRESS INFORMATION Cy ADOflE55 T16 NEAREST CROSS STREET ✓8wl0`aaW 0 PARTNERSHIP ElS1AiE AGENLY CITY NAME 0 Go 10 0 LOCAL AGENCY 0 FEOEW.AGENCY TATE ZIP CODE 1^ 0 INONIOIIAI 0 COUNTYAGENCY'( „ S I �-C SITE PHONE p,WITH AREA CODE TYPE OF BUSINESS: ❑2 DI RIBUTOR CA ❑ 4 PROCESSOR '/Box if INDIAN EPA ID p ❑ I GAS STATION ❑3 FARM OTHER RESERVATION or TRUST LANDS ❑ Mol TANKS EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE W WITH AREA CODE NIGHTS: NAME(LAST,FIRSTI PHONL p WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP ❑ D CORPORATION 0LOCAL-AGENCY STATE- AGENCY CITY NAME 0 INDIVIDUAL ❑ COUNTY- 0 FEDERAL-AGENCY AGENCY STATE ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to i Wicate 0 PARTNERSHIP 0 STATE-AGENCY CORPORATION 0 LOCALAGENCY ❑ FEDERALAGENCYCITY NAME ❑ STATE INDIVIDUAL ❑ COUNTYAGENCY ZIP CODE PHONE p,WITH AgEA 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. ElII. E] 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&SIGNATUREI DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION M AGENCY M FACILITY ID N Al of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID E `� APPROVED BY NAME PHONE M WITH AREA CODE S c)GI(="Lr PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACTX SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO CHECK F ❑ Q yG PERMIT AMOUNT SURCHARGE AMOUNTa / FEE CODE RECEIPTN Y: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INF ATION ONLY. FORMA(3-2-88) (0 * DATA PROCESSING COPY