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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD wr. yE\, a > �,A M FORM `A': UNDERGROUND STORAGE TANK PROGRAM }'o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Cq SfFOR N\F COMPLETE THIS FORM FOR EACH F ILITY/SITE [MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER Y CLOSED SVTE ONE' ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS --- (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ❑✓ AxMM ON ❑ LADDAL RSHIEIP ❑ FEDENA GENCtGY ❑ INDIVIDUAL ❑ WUNTY-AGENCf STATE ZIP CODE SITE PHONE #, WITH AREA CODE CITY NAME .�G a-. CA TYPE OF Bu INESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box it INDIAN EPA ID a N of TANK's 5 OTHER RESERVATION or AT THIS SITE ®1 GAS STATION 0 3 FARM TRUST LANDS ❑ EMERGENCY CONTACT PE ON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST. FIRST) PHONE # WITH AREA CODE DAYSNAME (LAST, FIRST) PHONE k WITH AREA CODE NIGHTS: NAME (LAST. FIRST) PHONE M WITH AREA CODE I NIGHTS: NAME (LAST, FIRST) PHONE it WITH AREA CODE II. PROPERTY OWNER INFORMATIO ADDRESS - NAME MAILING or STREET ADDRESS CITY NAME Ill. TANK OWNER INFORMATION & ADDRESS — (MU NAME MAILING or STREET ADDRESS CITY NAME UST BE COMPLETED I CARE OF ADDRESS INFORMATION ✓Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION Q LOCAL -AGENCY Cl FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY STATE I ZIP CODE I PHONE 0, WITH AREA CODE BE COMPLETED) CAREOFADDRESSINFORMATION Vxo ❑ PARTNERSHIP ❑ STATE-AGENCYN ❑ LOCAL -AGENCY ❑ FEDERAL-AGENCYCOUTY-AGENCYSTAZIP CODE PHONE q, WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIEI CT AND BILLING: I. ❑ IL ❑ III. ❑. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, fS TRUE AND CORRECT. APPLICANT'S NAME {PRINTED & SIGNATURE) LOCAL AGENCY USE ONLY DATE 7WS 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)