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STATE OF CALIFORNIA WATER RESOURCES CONTROL to sa FORM 'A': UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Cqb PORMP COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE O ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE W I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) �p CARE OF ADDRESS INFORMATION wilk FACILITY/SITE NAME 04 ADDRESS ENEARESTOSS STREET ✓mloiMdate 0 PARTNERSHIP 0 STATEAGENCY❑ CORPORATION 0 LOCAL AGENCY 0 FEDERALAGENCY ��/ � � 0 INDIVIODAL 0 WDN AGENCY 7 ZIP CODE SITE PHONE p,WITH AREA CODE CITY NAME jopL TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a _ X of TANMa RESERVATION or ❑ AT THIS SITE ❑ 1 GASSTATION ❑3 FARM ❑ 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE IT 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 IT WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME Fi�-rEL MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY STRECl0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL Cl COUNTY-AGENCY ITH AREA CODE STATE ZIP Dy/- / PHONE a.W CITY NAME 00 � I III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY STATE ZIP CODE PHONE q,WITH AREA CODE CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. El 11. El III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION% AGENCY# FACILITY ID IT If o7EE c� � CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE PERMIT EXPIRATION DATE PERMIT NUMBER PERMIT APPROVAL DATE DATE FI LOCATIO CODE CEN8U5 TJRACzM_ SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED /� �� YES ❑ NO ❑ G' P CHECKX PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: ~1 THIS FORM MUST BE ACCOMPANIED BY AT LEii MORE TANK PERMIT FORM B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ] \V\/J FORMA 13-2-881 DATA PROCESSING COPY 0.