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STATE OF CALIFORNIA WATER RESOURCES CONTRO ARD , , FORM A: UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/o PERMIT APPLICATION COMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C OSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME f CARE OF ADDRESS INFORMATION 00=—S. �S ADDRESS �/� //� NEAREST CROSS STREET=-/CORPBwtORATION Cl PARTNERSHIP ❑ FEDERAL AGENCY V /I�TIj GNNOR1ilON ❑ LOGLERSHIP ❑ STATE AGENCY NDNIDUAL ❑ CGUNTI'-AGENCY CIN NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE CA �2n� TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box ii INDIAN EPA ID N M of TANK'sION ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYDS or ❑ AT THIS SITE IAN 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 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ 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 ✓Bax to indicate ❑ PARTNERSHIP [3 STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 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: 1. ❑ 11. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION R AGENCY K FACILITY ID R N of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE KD F22 a PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [LOCATION CODE CENSUS TRACT k SUPERVISOR DISTRICT CODE BUSINESS S NFILED NG DAY I23. 2 3 PERMIT XSWINIT SURCHARGPWWUNT FEE CODE RECEIPT M B A� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFFOORRMATION(ONI . \ FOR (3-2-BB)