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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD , FORM A: UNDERGROUND STORAGE TANK PROGRAM Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY SED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) ~ A FACILITY/SITE NAME CARE OF ADDRESS INFORMATION X10 7, 016C IMC, ADDRESS NEAREST CROSS STREET kd' ��d✓9a ❑ PAawsi4P ❑ STATE-AGDKY / / 11 IND Tm ❑ LOCAL A�AGENCY ENGY 11FEDERAL-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE AJ CA LU2_0 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box d INDIAN EPA 10 N N of TANK' h/ ❑ 1 GABSTATION ❑ 3 FARM ❑ 5 OTHER TRUSRESETVATION LANDS o, ❑ AT THIS SITE 4/ 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 N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 7 . MAILING or STREET ADDRESS �✓� B tJIndicate El PARTNERSHIP 13STATE-AGENCY �E33�CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE P ONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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 N JURISDICTIONIF AGENCY A, CILITY ID R N of TANKS at SITE CURREN LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHO E N WITH AREA CODE a� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L DE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL 9 _23-10YES ❑ NO ❑ �� PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: eS 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. A(3-2-813) *%W DATA PROCESSING COPY 7F