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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM uo z 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 F'J ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY�TE N E CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓ft Nindtile Cl PARTNERSHIP C STATE-AGENCY �3 C CARPDRATIDN Cl LOCAL AGE10 0 FEDERAL AGENCY �� ✓ C INDMDUAL 0 OOUNTY-AGENCY CITY NAME STATE 21P CODE SITE PHONE N.WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Boz if INDIAN EPA ID # ❑ 1 GASSTATION ❑ 3 FARM OTHEfl TRUSTESEVLANDS ATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME OAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE 2 - 6 NIGHTS'. NAME(LA T,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CAFADDRESS INFORM ION N. MAILING or STREET ADDR SS ✓Box to indicate C PARTNERSHIP 0 STATE-AGENCY ❑ C ATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY DIVIDUAL Cl COUNTY-AGENCY CITY ME STATE ZIP CODE PHONE K,WITH AREA CODE 9s(o 3 a- 2 o9 s= III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS \ ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY C INDIVIDUAL C 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. ❑ 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# AGENCY# FACILITY ID# #of TANKS at SITE ® a 3 -7 s CUR7NT LOCAL AGENCFACILITY IDN APPROVED BY NAME HONE N WITH AREA CODE f PERMIT NU BER PERMIT APPROVAL GATE PERMIT EXPIRATION DATE LOCATION ODE CENSUS TRA N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL 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. /FORM A(3-2-88) - (/('// �s DATA PROCESSING COPY 44*4