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STATE OF CALIFORNN WATER RESOURCES CONTROBOARD 'E ''`0 , �� ,, FORM ' A: UNDERGROUND STORAGE TANK PROGRAM .o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 1:95 CHANGE OF INFORMATION ❑ 7 PERMANENT Y CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE rpcl 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION k`_'-f- ADDRESS NEAREST CROSS STREET ✓BmbF6iule 0 PARINERSHIP 0 STATE AGENCY �, 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL S_ e D INDMDUAL Cl MUM AGENCY CIN NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE v ti CA TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA 10 Al N of TANK's RESERVATION arAT THIS SITE ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP D STATE-AGENCY 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bav toinoicate 0 PARTNERSHIP D STATE-AGENCY ❑ CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVB ADDRBBB 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYIF JURISDICTION N AGENCY M FACILITY ID R M of TANKS M SITE " 1 1 12 3 CURRENT LOCAL AGENCY F2AMOUNT APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED —>26 YES NO CHECK N PERSURCHARGE AMOUNT FEE CODE RECEIPT N BY: C IS FORM MUST BE ACCOWANIED BY AT LEAS R MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 A(3288)