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STATE OF CALIFORNIX WATER RESOURCES CONTRO"OARD FORM'A': UNDERGROUND STORAGE TANK PROGRAM =� SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA) Y C OSED SI L MARK ONLY ❑ f NEW PERMIT ❑ ONE ITEM n 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) �wwnl.0 NBAI ICT 10111C nmol cTFFTI rnvrrnl T CARE OF ADDRESS INFORMATION NAME AGENCY E CARE ADDRESS INFORMATION "" t L ^ G6mloN POOL Mo CARE OF ADDRESS INFORMATION `OF� CWIwoN FACILITY/SITE NAME MAILING mSTREET rr`/ CURRENT LOCAL AGENCY FACILITY ID N /iN e/^ ❑PARTNERSHIP 0 STATE -AGENCY ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ADDRESS ZIP CODE ❑ INDIVIDUAL NEAREST CROSS STREET ✓Bmbloirpb / 0 CowmTo 0 PANTNERSIIIP 0 STAME ENC/ 0 LOCNAGDO 0 REMPNAGDO 5 w STATE ZIP CODE PHONE p, WITH AREA CODE 6 7 oe /s' - 635- 0 C { OOH7/S 0 INONIDUAI ❑ WUN YAGRC CENSUS TRACT • SUPERVISOR -DISTRICT CODE STATE ZIP CODE SITE PHONE It, WITH AREA CODE CITY NAME CA 1;'20 57- YES C] NO 0 5 oc oxo PERMIT AMOUNT SURCHARGE AMOUNT TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N F of TANICI ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or ❑ TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE p WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE N WITH AREA CODE u - b -O O NIGHTS: N E (LAST. FIRST) PHONE p WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE p WITH AREA CODE �wwnl.0 NBAI ICT 10111C nmol cTFFTI rnvrrnl T CARE OF ADDRESS INFORMATION NAME AGENCY E CARE ADDRESS INFORMATION "" t L ^ G6mloN POOL Mo `OF� CWIwoN iJ'�b MAILING mSTREET rr`/ CURRENT LOCAL AGENCY FACILITY ID N ✓Bwtoinoicate ❑ CORPORATION ❑PARTNERSHIP 0 STATE -AGENCY ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY RADDRESS �' �fTj 6 �� ZIP CODE ❑ INDIVIDUAL ❑ COUNTY -AGENCY Wx CITf NAME PERMIT NUMBER STATE ZIP CODE PHONE p, WITH AREA CODE 6 7 oe /s' - 635- 0 e vI!/e, PERMIT EXPIRATION DATE III• TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRBBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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 8 SIGNATURE) DATE 1100 null v CARE OF ADDRESS INFORMATION NAME AGENCY E FACILITY ID E E of TANKS at SITE ✓Boa to in0icate ❑ PARTNERSHIP 0 STATE -AGENCY MAILING w STREET ADDRESS 0 CORPORATION 0 LOCAL -AGENCY 0 FEDERAL -AGENCY CURRENT LOCAL AGENCY FACILITY ID N 0 INDIVIDUAL 0 COUNTY -AGENCY APPROVED BY NAME STATE ZIP CODE PHONE N, WITH AREA CODE CITY NAME PERMIT NUMBER PERMIT APPROVAL DATE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRBBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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 8 SIGNATURE) DATE 1100 null v FOIIY MUST BE ACCOMPANIED BY AT LEAST (1) OR LRE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF BETE INFORMATION ONL FO LB'x-RBI VOW COUNTY # JURISDICTION E AGENCY E FACILITY ID E E of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE p WITH AREA CODE SC-RpSoc PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUS TRACT • SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED DATE FILED ELOCA"OMOODE YES C] NO 0 / 3/ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTI BY: FOIIY MUST BE ACCOMPANIED BY AT LEAST (1) OR LRE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF BETE INFORMATION ONL FO LB'x-RBI VOW