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STATE OF CALIFORNIr WATER RESOURCES CONTROL-dOARp FORM 'A': UNDERGROUND STORAGE TANK PROGRA t SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLI TION G COMPLETE THIS FORM FOR EACH FACILITY/SITE 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 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME _ CARE OF ADDRESS INFORMATION rra�� .� e�' !.v S ADDRESS NEAREST CROSS STREET ✓BPbioUlle ❑ PARTNUB9P ❑ STATEAGDILY ❑ COWMTON ❑ LM-ABENLY ❑ FEGBUL-AGENCY ❑ INBMDUAL ❑ CGINIV-Af81IX CITY NAME STATE ZIP CODE SI TE PHONE N,WITH AREA CODE S a k CA S TYPE OF BUSINESS: ❑ 2 DISTRIBUTDR ❑ 4 PROCEBSOR ✓Box if INDIAN EPA ID a ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUSTVLANDS ATION or ❑ AT TN 8 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 II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate V ❑ PARTNERSHIP ❑ STATE-AGENCY O CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/Box toindlcate ❑ 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 ADDRISS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: Lim it. ❑ Ill.❑ 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 R JURISDICTION R AGENCY B FACILITY ID R P of TANKS at SITE Jr CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE roloso 7A PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE gRM ODE CENSUS TRACT• SUPERVISOR-0ISTIIICT CODE BUSINESS PLAN FILED DATE FILED O S� YES NO / PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT F BY: MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERIAIT FORM'B'APPLICATION(S),UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY.