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STATE OF CALIFORNIP WATER RESOURCES CONTROL "BOARD 9e�� 1ti\ f FORM `A': UNDERGROUND STORAGE TANK PROGRAM o SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 NEN PERMAY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME r CARE OF ADDRESS INFORMATION , r. ADDRESS A a NEAR TCROSS STREET 4rl• //Ilf / f,^L J/�l � V/ ✓,_V- BOW m 13 PARTNERSHIP ❑ STATE AGENC Cl RAT10N 13 LOCAL AGENCY ❑ FEDER4LAGENC ! BOW ❑ CaUNTYAv CITY NAME A STATE ZIP CODE SITE PHONE#,WITHAREA CODE CA Jrc� 3 - .Z " TYPE OF BUSINESS. ❑ 2 DISTRI UTOR F—] 4 PROCESSOR ✓Box II INDIAN EPA ID # $ofARM TRUST LANDS 5 OTHER RESERVATION or ❑ 1 GASSTATION AT THIS SITE ❑ ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYSNAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING 0,VREET ADDRESS I/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ 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: I. 0it. ❑ 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 R FACILITY ID R It of TANKS AI SITE I L I I (AS° D 60 CURRENT OCAL 1!37 FACILIT ID N APPROVED BY NAME PHONE N WITH AREA CODE l� PERMIT NUMBER PERMIT APPROVAL DATE PERMR EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPER CODE CODE BUSINESS PLAN FILED DATE FILED q('j _J 7 7 YES NO CHECIkN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# B THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88)