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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM »o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY ❑ 1 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 57 I. FACILITY/SITE INFORMATION 8 ADDRESS— (MUST BE COMPLETED) FACILITY; NAME . CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓BNbixFAle ❑ PAAffIJMP ❑ STATE AGENCY T0 o IN ALS 11 `Cq AMLY ❑ EX4 AGEN CITY NAME STATE ZIP COPE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS. 2 DISTRIBUTOR ❑4 PROCESSOR ' ox if INDIAN EPA ID N RESERVATION or N of TANICF E] f GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS 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(UST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION III ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP O STATE-AGENCY ❑ 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 ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl 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 BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY � COUNTY R JURISDICTION R AGENCY N FACILITY ID B 0 of TANKS at SITE 'E CURRENT LOCAL A CY FACILITY ID N APPROVED BY NAME PHONE F WITH AREA ODE C PERMIT NUMBER PERMITAPPROVALDATE PERMIT EXPIRATION DATE A LOCATION CODE CENSUS TRACY N SUPERVISOR-0IBTIIICT CODE BUSINESS PLAN FILED DATE FILED �3. Z YES [:] NO ❑ 5 90 / CHEC F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: J1 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. .VY FORM A(3-2-88)