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STATE OF CAL I FO R N h-� WATER RESOURCES CONTR&--BOARD 4, FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bac io. ❑ PAFTNEft5f1P ❑ sw&AGea CC,!/V� ❑ r l 1� ❑❑ ` -AAE AGGY ❑ REAL-AGB+cr A< CIN N ME STATE ZIP CODE SITE PHONE#.WITH AREA CODE C_k'4 r CA a Q a o TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ {PROCES7RI�E Box f INDIAN EPA ID # ❑ ) GAS STATION ❑ 3 FAAM �.69T1 1STVLANDS or ❑ t of HIS Srl AT rHls sere EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE ('-z0 NI HTS: NAME( ST,FIRST) HONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATIO ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS—(MUST E COMPLETED) NAME '11ADDRESS INFORMATION E OF MAILING or STREET ADDRESS ✓B'bKto indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CO ORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIV UAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE Id. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATIO ND BILLING: I. II. 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY OWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) TE LOCAL AGENCY USE ONLY F JURISDICTION# AGENCY# FACILITY IDN #of TANKS Ct SITE EI I I 60 1 AGENCY FACILITY ID 4 APPROVED BY NAME PHONE 0 WITH AREA CODE PERUIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUS TRACT R O SUPERR ICT CODE BUSINESS PP Q O YES NO ❑ DAT rHE� PEfiNIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• BY- THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK Pew FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORUATION ONLY- FORM A(3-2-118)