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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD f ti A i FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT E 13 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑•4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I� r I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME j� CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bux,roole ❑ PAinflIHIP ❑ STATE AGENCY 2L{ ElCOWOMMI TION ❑ LOCAL-AGENCY ❑ RO .AGENCY 11 ROM OUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE TD CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # ❑ t GAS STATION ❑ 3 FARM ❑5 OTHER RSERTRUSTYATION LANDS or ❑ #of TAMP# 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 It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STgTE ZIP CODE PHONE#.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME 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#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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 It IF of TANKS at SITE 12 CO] CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE 0 WITH AREA CODE „I RMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE V LOCATION 1 CODE CENB��0 SUPERVISOR-DISTRICT DISTRICT CODE BUSINESS PUN❑:] NO ❑ DATEFILED /^ Z lV I CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST 17)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLGSS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-SS) -- DATA PROCESSING COPY -,-.