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l-- STATE OF CALIFORNIA- WATER RESOURCES CONTROL--BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM a � " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 a COMPLETE THIS FORM FOR EACH FACILITY/SITE — I I MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 ffBMAPfNTLY CLOSED SITE 1-46ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 8 N cc I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE NAME l CARE OF ADDRESS INFORMATION II ADDRESS NEAREST CROSS STREET ❑/Butniggegg ❑ LOCA4Aw ❑ FsTATEAGDO TALRLL 6a Rlcr I u ❑ N[MGaL ❑ OWMAGBICY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE S CA ef :Z TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓BOX if INDIAN EPA ID N RESERVATION or #IH TANK'# ❑ 1 GAS STATION ❑3FARM ❑5OTHEfl TRUSTLANDS ❑ 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 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 MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNT'-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intimate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.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: L ❑ U. ❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE CURRENTLOCALAGENCYFA ILI IDN APPROVED BY NAME PHONE N WITH AREA COD PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED D YES ❑ NO b �� -f CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT I! BY: 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 13-2-881 i DATA PROCESSING COPY