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STATE OF CALIFORNI)w WATER RESOURCES CONTROrtOARD :s `^ 'E' FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m o COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��oa�`" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT' ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE I� ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE j I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) OD co FA TV/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS133 NEAREST CROSS STREET ✓Bainb ❑YARINERERP 11 STATE AGENCY ❑ CGI MDON 11LOCAL-AGEID 1:1 FEDERAL AGENCY L ❑ INDIVIDUAL 11COIRlIKAGENCY CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE CA TYPE OF BUSINESS: ❑Z DISTRIBUTOR ❑4 PROCESSOR ✓Bond INDIAN EPA ID# ❑ 1 GAS STATIONRS:j FARM ❑50THER TRUSTLANDS TION 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 N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/B0.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓SO.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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: L ❑ 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 B AGENCY R FACILITY ID R M of TANKS at SITE CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE PERMIT N MBER I I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION ODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO ❑ 3 CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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. I FORM (3 -SB) / I CI DATA PROCESSING COPY I