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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE ONE ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ` 2 INTERIM PERMIT ❑N AMENDED PERMIT ❑ T PERMANENTLY CLOSED SITE ❑ N ❑fi TEMPORARY SITE CLOSURE ai I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) m FACILITY/SITE NAME rV CARE OF ADDRESS INFORMATION ADDRESS FH 2� I� NEAREST CROSS STREET ✓bA 0 M1g12 ClPARTNERSHIP LlSTATEAGENCY C. O IZ! ❑ CORPORATION 1:1LOCAL AGENCY ❑ FEDERAL AGENCY CITY NAME STATE 1 INDIVIID ❑ COUNIYAGENCY L I ZIP,CODE SITE PHONE N,WITH AREA CODE TYPE OF BUSINESS' CA ❑ 2 DISTRIBUTOR ❑q PROCESSOR ✓Box if INDIAN EPA ID N ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or N of TANK', AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) TRUST LANDS ElEMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAMELAST,FIRST)) PHONE q WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(IAST,FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to,nd,Latc ❑ PARTNERSHIP STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box tolntlicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ 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 BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ 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 N JURISDICTION N AGENCYLV FACILITY ID N N of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DI ICT CODE BUSINESS PLAN FILED DATE FI D 2 YES NO CHECK, PERMIT AMOUNT SURCHARGE A UNT FEE CODE RECEIPT p BY. 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._ 1 FORMA(3-2-88) U C�L ,a DATA PROCESSING COPY v vmw \ VV