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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 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 ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Sb I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Vi 6Corn ADDRESS I NEAREST CROSS STREET ✓SNwNuV ❑ PARTNEASHIP ❑ STATE AGENCY 2 � �. i On•v�Gt ❑ COWDIIATION ❑ LOCAL AGENCY ❑ FEDEW AGENCY ❑ INDIVIDUAL ❑ COOTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE STa= dn/ CA S.zdZ TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4PROCESSOR ✓Box if INDIAN EPA ID p RESERVATION or ❑ XoI TANMF ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS 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 N 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 ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERALAGENCY ❑ 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 ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE X.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. ❑ 11. ❑ 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 x JURISDICTION X AGENCY X FACILITY ID X X o/TANKS at SITE 3q 3 CURRENT LOCAL AGENCY FACILITY ID R APPROVED BY NAME PHONE F WITH AREA CODE /Nz- (r'bf`_ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA CENS118TRACT36X SUPERVISOR ZS-DISTRICT CODE BUSINESS PLAN FILED DATE FILE 2YES NO � 6 o PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTX BY: p THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS 11 A CHANGE OF SITE INFORMATION ONLY.