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NNW _ STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': - UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' o:. COMPLETE THIS FORM FOR EACH FACILITY/SITE C�iIF� SP MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS 7- (MUST BE COMPLETED) FAGIL ITV SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓i-TGVuIe ❑ PARTNERSHIP ❑ STATE-AGENCY N , ) ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEOERAL-AGENCY C" _— ❑ INDIVIDUAL ❑ COUNTY AGENCY CITU NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE CA TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Box It INDIAN EPA ID a RESERATION or❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TTRUSTT LANDS ❑ N of TANK 1ATTHIS 517E 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 a WITH AREA CODE NIGHTS NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING of STREET ADDRESS ✓Box to melcate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CI7Y NAME STATE ZIP CODE r464E_a,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓box to incrcale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ClFEDERAL-AGENCY ClINDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,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: L II. ❑ 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY F JURISDICTION N AGENCY N FACILITY ID M N of TANKS a1 SITE lD C�AGENCY FACILITY ID R A 'P YED BY NAM PHONE A WITH AREA CODE 7DC-k 12 PERMIT APPROVAL DATE PEI MIT EXPI TION DATE CENSUS TRACT N SUPERVISOR-DISTRICT CODE _ BUSINESS PLAN FILED DAT FtL D YES NO [:] 9 CHECK R PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 4 BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION