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STATE OF CALIFORNI10 WATER RESOURCES CONTROL BOARD E' E' A FORM 'A': ami UNDERGROUND STORAGE TANK PROGRAM ' SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° d COMPLETE THIS FORM FOR EACH F CILITY/SITE .�a-`" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Ln3 -4 I--a I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FAQ1iAME � CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Box loi rale El PARTNERSHIP [I STATE AGENCY D GIVIGOALION FI CONNAGENCY FEDERAL AGENCY CITY NAM STATE ZIP CODE SITE PHONE#,WITH AREA CODE 'r` CA -S -30?5� TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR I/Box if INDIAN EPA ID # RESE❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TTRUSTYLANDS ATION o ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE it WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box lo,n0icale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNIER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE If 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. ❑ if. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID At It of TANKS at SITE ,= CURRENT LOCAL AGENCY F7L17Y/ID y,�/ APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER L/ A/I6 �TI- PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILED ( a3 YES ❑ NO ❑ �" //d),E CHECKIT PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:/ 7 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. FORM A(31 DATA PROCESSING COPY '