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STATE OF CALIFORNI'k WATER RESOURCES CONTROL BOARD "i�:. "F FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �' �' SITE n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -m r �� 10 `/ 1 0 COMPLETE THIS FORM FOR EACH FACILITY/SITE `'A,ron�`°' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I" ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 8 (" I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) N FACILITY/SITE NAME CARE OF ADDRESS INFORMATION O C ADDRESS/d-��--11 NEAREST CROSS STREET ✓ IOm4kale BWPARINEASHIP C STATE AGENCY �� L. G ❑ CORPORATION ❑ LGCALAGENC+ ❑ FEDERALAGENCY C INDMUUAL C WUNIYAGENCY CITY NAME STATE ZIP CODE SITE PHONE A.WITH AREA CODE STXiIJ CA TYP F BUSINESS: ❑p DISTRIBUTOR ❑4 PROCESSOR ✓Box A INDIAN EPA ID N r If of TANICS I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LAN S VATION N ❑ 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#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE H WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate C PARTNERSHIP C STATEAGENCY C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY ❑ INDIVIDUAL C COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box tolndicate C PARTNERSHIP C STATE-AGENCY ❑ CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY C INDIVIDUAL C COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE I IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. I I APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE 5 CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT UM ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [CHECK OCATION CODE CENSUS TRACT It SUPERVISOR•DISTRICT CODE BUSINESS PLAN FILED DATE FILE YES NO 31,? N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: aaaalill THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INF77 / ORM A(3-2-BB) NOW' DATA PROCESSING COPY -.