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STATE OF CALIFORNIX WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PRMIT APPLICATION o o 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 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) ~ GO FACILITY/ TE NAME CAREOFADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bolbbtlbak NRNEFiGHIP ❑ GTATEAGENCY D COIPORAIKNI LCCALAGENCY ❑ FEDERAL AGENCY D INOMDUAL ❑ WUNWAGEND CITY NAME STATE ZIP CODE SITE PHONE a.WITH AREA CODE CA TYPE OF BUSINESS. ❑ STRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID A RESERVATION or X of TANK'a ❑ 1 GASSTATION 73 FARM ❑ 5OTHER TRUST LANDS ❑ ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(IAST,FIRST) PHONE a 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 0 STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERALAGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP Cl STATEAGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY C INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS ZZ CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. Er it. ❑ 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 M JURISDICTION a AGENCY R FACILITY ID a a of TANKS at SITE = = = 1 1 14 v 3 CURRENT LOCALA NC�Y FACILITY IO M APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER x/�4j5 L PERMIT APPROVAL DATE PERMIT EXPIRATION DATE jLZ0CATl5kNDE CENSUST11I1CT SUPEXV R-DISTRICT CODE BUSINESS PLAN FILED ❑ DA fLED3 C//�� YES NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN ITHIS 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. r •Vn`Yt FORM A(3-2-88) %W DATA PROCESSING COPY �/6