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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD y`Pk- f' FORM `A': " t UNDERGROUND STORAGE TANK PROGRAM 'u0 SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I C COMPLETE THIS FORM FOR EACH F ILITY/SITE �Cy`.FORN�.P MARK ONLY ❑ 1 NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El PERMANENT ED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 F—� I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 'p W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓ scale ❑ PARTNERSHIP ❑ STATE-AGENCY / ORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE Si E PHO E a.WITH AREA CODE CA 53w5M,23X3,0 T YPE� S ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box ii INDIAN EPA ID a / RESERVATION or #of TANK's ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHON WITH AREA CODE NIGHTS. NAME(LAST,FAST) V11 4111 PHONE#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 or STREET AD KESS ✓Box to indicate El PARTNERSHIP 1:1 STATE-AGENCY �•1 ElCORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY (/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATEZIP CODE PHONE a,WITH AREA CODE r,4- s30 3s'-z7s� Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAMES CARE OF ADDRESS INFORMATION Cto MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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: 1- ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE F/ ly- l (eTl CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED © - 0 ) 1 YES ❑ NO ❑ Q CHECK# PERMIT AMOUNT SURCHARGE AMOUNT ___FFEE CODE RECEIPT# BY: 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. ORM A(3-2-88) - DATA PROCESSING COPY