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STATE OF CALIFORNM WATER RESOURCES CONTROL BOARD �' r"' FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE �9tr.GPM�P MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT PIS CHANGE OF INFORMATION ❑ 7 PEAy_&UEUI4 CLOSED SITE Q ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ' I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W CO FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Will +V R o ADDRESS NEAFtEST CROSS STREET ✓BmbigcY ❑ PAATNRBNP ❑ STATE AGENO! CA Q r-L. ❑IllWR O MGMDK ❑TCN 13LOG4AGDO ElRDEML.KOO C. 1 WIIIIIY.AGDO CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Bax if INDIAN EPA ID p RESERVATION or p of TANK'a ❑ IGAS STATION ❑ 3FAAM +OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT rERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE 11. PROPERTY OWNER INFO ATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY— CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE Ill. TANK OWNER INFORMATION &A RESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to inEicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRE CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BEED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. El if. El Ill.El THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER RY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY p FACILITY ID If p of TANKS at SITE 1pEo011l CURRENT LOCAL AGENCY FACILITY ID t APPROVVEED BY NAME PHONE p WITH AREA CODE {1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE I CENSUBTRACTS SUPERSDR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED � ol YES NO 3 1,9 eq CHECK p PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N Y: 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. FORM A(3-;- f, ^ / l\ 'M`v I DATA PROCESSING COPY ""