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STATE OF CALIFORNIA WATER RESdUACES CONTROLBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 o COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDSITE 1-A ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 6 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) N FACILITY/SITE NAME CARE OF ADDRESS INFORMATION A ADDRESS NEAREST CROSS STREET ✓&abidvak ❑ PA EWIP ❑ STATE-ARKN ❑ CgR'OIBTON ❑ LOGL-AGENCY ❑ FBXIVLAGDKY Com- ❑ INDMBIN ❑ COUMY-AGFNGY CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE CA TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Boz it INDIAN EPA ID a p of TANICN ❑ ❑ RESERVATION or ❑ 1 GAS STATION F-13 FARM ❑5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST.FIRST) PHONE a 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 p WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CA RE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 1.WITH AREA CODE 111. TANK 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 ❑ COUNTY-AGENCY CITY NAME STATE - ZIP CODE PHO HE 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. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COQ J--/-J JURISDICTION � AGEL--�—�J FACILITY IDM N of TANKS H SITE CURRENTLOCAL AGENCY F CILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBEfl PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS T11A N SUPERVI - 8 flICT CODE BUSINESS PLAN FILED DATE F a3• YES ❑ NO Z- CHECKN PERMIT AMOUNT SURCHARGE-AMOUNT FEE CODE RECEIPT BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM'B'APPUCATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) DATA PROCESSING COPY 1.414