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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION RA ADDRESS N REST CROSS STREET ✓IN,bmA ClPAIITNEIEHIP ❑ STATE AGENCY ❑ C71PGt/TIGN ElLOCALAWIC! [IFEOEML-AGENCY ! I. 1:1NONDUk ❑ WUNTY.AGENCY CITY NAME �/ STATE ZIP CODE SITE PHONE N,WITH AREA CODE / � CA 2,D / TYPE OF BUSINESS'. ❑ p DI OR ❑ 4 PROCESSOR ✓Boz it INDIAN EPA ID N S ❑ RESERVATION Or ❑ •o1 TANKY ❑ i GAS SFATION FAR1A 5 OTHER 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 N WITH AREA CODE Lf oZ d 3,1 ;14 oz — NIGHTS: NAM ST,FIRST) PHONel WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE N WITH AREA CODE S 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S MAILING or STREET AD ESS ✓Boz toinJicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATS ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADRESS ✓Bon 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 V/HICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ Ill. ❑ 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 JURISDICTION M AGENCY R FACILITY ID R Al of TANKS at SITE CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LClECKd E CENSUS TRACT BUPERVISOR-cDI�ETRICT CODE BUSINESS PLAN FILED DATE r� 3 P �� YES � NO PERMIT AMOUNT BUflCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCO ANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 1FORM�-BB� ��/\ � WI v