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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE `'Ar.a•�' MARK ONLY ❑ 1 NEWPERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑p INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE S I Z I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 1 FACILITY/5 NAME � CARE OF ADDRESS INFORMATION ADDRESS — NEAREST CROSS STREET ✓BwgPAoI* 0 NAPTNASNP ❑ STATE AGENCt N 0/lJ ❑ oacoNAnoN ❑ LxA ADEN Y ❑ RDEAA AGEN ❑ INOMDUAI 0 COUNW AGENCY —4 CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE 0 CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Bal A INDIAN EPA ID N ❑ 1 GAS STATION ❑ 3 FARM ❑5 OTHER RESERVATION a ❑ N of TANK'N AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME IIAST.FIRST) PHONE N WITH AREA CODE DAYS NAME(UST.FIRSTI PHONE N WITH AREA CODE Lwtj NAME)LAST.FIRST PHONE N WITH AREA CODE NIGHTS NAME(LAST_FIRSTI PHONE N WITH AREA CODE HTS E iLlAllyl IF 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boa to m,cala ❑ PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION O LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAMF CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boa to mrcata 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCALAGENCYCl FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 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 COUNTY10 JURISDICTION N AGENCY N FACILITY ID N N of TANKS SI SITE [= I I I� 3 / 3 d CURRENT LOCAL AGENCY FACILITY IO N A _711OVEDBYHAlr ,I PHONE N WITH AREA CODE FI L PERMIT NUMBER PERMIT APPROVAL DATEPERMIT. (RATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE SUSINESS PLAN FILED DATF FILE YES E] NO PEAMOUNTCHCRMR SURCHARGE AMOUNT FEE CODE RECEIPT N T: II THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)0--'-RE TANK PERMIT FORM 'm` APPLICATION(S), UNLESS T"'"'S A CHANGE OF SITE INFORMATION ONLY.