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STATE OF CALIFORNMC WATER RESOURCES CONTROL BOARD FORM `A': �. UNDERGROUND STORAGE TANK PROGRAM Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F CILITY/SITE I O MARK ONLY ❑ I NEWPERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N FACIU ITE NA E CARE OF ADDRESS INFORMATION ADDRESS — NEAREST CROSS STREET ,✓ 0 PARTNERSHIP 0 STATE AGENCY Ill UJid' TI N ❑ LGCAL-AGOICe 11 {EDBUL AGENCY CITY NAME ❑ INOMWAL ❑ COUNTY-AGENCY I STATE ZIP CODE SITE PHONE A.WITH AREA CODE CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑A PROCESSOR ✓Box ii INDIAN EPA 10 p ❑ 1 GAS STATION FARM ❑ 5 OTHER TRUST LANDS VATION Or ❑ N of TANKY y 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 I WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toinoicale ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY El INDIVIDUAL ❑ COUNTY-AGENCY CITU NAME STATE ZIP CODE PHONE 1.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to,nd,,ote ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE I$,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 N JURISDICTION N AGENCY k FACILITY ID N It of TANKS at SITE CURRENT LOCAL AGENCY FACILITY IDA APPROVED BY NAME PHONE N WITH AREA CODE l f_�TDn PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA ODE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DA FILED � YES NO 1:1 / I� _f CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: ITHIS 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. 1Y'NI FORM A(&2-88) �� DATA PROCESSING COPY *404