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STATE OF CALIFORNIA• WATER RESOURCES CONTROL90ARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ 1 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 - (MUST BE COMPLETED) FACILITY/SME NAME CARE OF ADDRESS INFORMATION �' rvt /�v ii✓r i1X�Y`f N ADDRESS �• NEAREST CROSS STREET ✓smbiocam, ❑ PWMEASHIP El STATE AGENC/ yoJ /V,— 0 No � 0 `LOCAL�AIB.'CY 0 R31E(BL.Ama CITY NAME STATE ZIP C�O•.D��'E' �� SITE PHONE N,WITH AREA CODE TYPE OF BUSINESS: a� CA � � _ Z ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓BOX B INDIAN EPA ID N RESERVATION or N of TANK'N I GAS STATION ❑3FAlIM ❑5OTHER TRUSTLANDS ❑ AT THIS SITE 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 IL PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION c O N MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP - ❑ STATE-AGENCY y�'� ❑ CORPORATION 11LOCAL-AGENCY 11FEDERAL-AGENCYC e- 11INDIVIDUAL ❑ COUNTY-AGENCY CITU NAME STATE ZIP CODE /� �PHONE N,WITH AREA CODE R SON .ZO t-c//— L III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME e as CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ 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. 0 II. ❑ IN.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED IS SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION If AGENCY N FACILITY ID M N of TANKS at SITE EEIo / ERE] I I 1 0 1 �/] CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATI NDATIS LOCATION CODE CENSUS TRACT N SUPERVISOR-0ISS/TRICT CODE BUSINESS PLAN FILED DATE FILED YES NO / CXECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RI CEIPTN BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLYY RMA(3-2-SS)