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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o 611, COMPLETE THIS FORM FOR EACH F ILITY/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 CD 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) f+' FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓ p0,1d,w0N Cl IOGLLM-PSHIPY 0 ST"A R-G:ENC C( T` (i(/�1 JL iNmvlouu ❑ counry-ABE ' AI�'�/ STATE ZIP CDDE �j / SITE WITH AREA COD �1 CITY NAME CA TYPE OF USINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID N N of TANK'N GAS STATION ❑ 3FARM ❑ RESERVATION or ❑ AT THIS SITE ❑ 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. N E(LAST RST) , PHONE p WIzF1 A7EA.CODE� DAYS NAME(LAST,a/( PHONE M WITH AREA CODE 14 NIGHTS'. NAME LAST,FIRST P`HHOA�NE N WITH IREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRE� I 4BOnftate I0 PARTNERSHIP0 STATE-AGENCY TION OLOCAL-AGENCY OFEDERAL-AGENCY L 0 COUNTY-AGENCY CITY NAME STAZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME �� CARE OF ADDRESS INFORMATION 5� as MAILING or STREET ADDRESS ✓Box to indic to 0 PARTNERSHIP 0 STATEAGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,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 N JURISDICTION N AGENCY N FACILITY ID k N of TANKS at SITE DI = = 0 01 11 Y DE Do 10 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE a WITH AREA CODE N 6 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N �� SUPERVISOR-018 T CODE BUSINESS PIAN FILED DATE FILED Q 1 2 YES NO [-] �+� CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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. l' FORM A(3-2-88) �,� DATA PROCESSING COPY +./