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STATE OF CALIFORNIX WATER RESOURCES CONTR Lo BOARD �f'l FORM `A': UNDERGROUND STORAGE TANK PROGRAM �� SITEL/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION L ` COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PE pLOSEO SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / m t,0 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) V FACILITY/SI AME CAREOF/POORESS INFORMATION ADDRESS �1// NEAREST OSS STREET ✓Butomute C PARTNERSHIP ❑ STATE AGENCY OD I /""-Y 1 ��GOAPORATION ❑ LOCAL ❑ FEDERAL-AGENCY ��'�Y�'�``��"��Y PINnIOUAL ❑ COUNTY- AGENCY CITY NAMESTATE ZIP CO TE PHO p,WITH AREA CODE Z. 1 CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box if INDIAN EPA ID k HESERI❑ If.1 TANK's I GASSTATION dFARM ❑ SOTHER TRUST LANDSG 1:1 ATTHIS SITE OI EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) 9PV6:�E(LAST,FIRST) PHO E p WITH AREA CODE DAYS E LAST.FIRST) PHONE p WIT AREA CODE `J C S 0 4 NIGHTS: NAME( BT) #WITH AREA CODE NIGHTS. N E(LAST,FIRST) PHONE#W TH AREA CODE Ii. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME I 'r CARE OF ADDRESS INFORMATION MAILING or BEET ADDRESS ✓Box tointlicate C PARTNERSHIP C STATE-AGENCY ❑ CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY C INDIVIDUAL C COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME /1 CARE OF ADDRESS INFORMATION MAILING a,STREET ADDRESS ✓Box tointlicate C PARTNERSHIP C STATE-AGENCY Cl CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY ❑ INDIVIDUAL C COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. Or 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 COUINTY M JURISDICTION R AGENCY k FACILITY ID a a of TANKS at SITE a 1 / CURB nnNT LOCAL AGENCY FACT ITY ID a APPROVED BY NAME PHONE Y WITH AREA CODE C l PERMIT NUMBER PERMIT APPROVAL DATE PII EXOIRATIOW DATE L E CENSUSTRACTA SUPERVI O RICT CODE BUSINESS PLAN FILED DAT ILEOi�j2j-Z YES NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 � ORM A(3-2-SB) / DATA PROCESSING COPY v v