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STATE OF CALIFORNI* WATER RESOURCES CONTReBOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - o COMPLETE THIS FORM FOA EACH FACILITY/SITE MARK ONLY yJ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT :HANGE OF INFORMATION ❑ 7 PERMANENT Y ri FISED SITE r ONE ITEM T INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION I ADDRESS NEAREST CROSS STREET ✓BoxpnEipk ❑ PARTNERSHIP 0 STATE AGENCY ❑ CORPORATION ❑ LOCAL AGENCY Cl FEDERAL... �-1J ( ❑ INOMi ElCONNN-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N ❑ T GAS STATION 3 FARM 5 OTHER RESERVATION or 1:1AT THIS SITE ❑ ❑ TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYSNAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST( PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST( PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓RDx m,nd,cate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,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 N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: I. ❑ 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 M JURISDICTION N AGENCY R FACILITY ID R N of TANKS at SITE m � � I I I IO 0:-0- CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE If WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LLOCATIO CODE CENSUS TRACTM SUPERVI�-DISTRICT CODE BUSINESS PSN FILED NO ❑ DATE FILED PERMIT C AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT B�^YI:, THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS MA CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-68) DATA PROCESSING COPY *mw