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STATE OF CALIFORNI; WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM a SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m ' o COMPLETE THIS FORM FOR EACHFACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT NrS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1'-T. ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 80 OD I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) w to F ILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Sm to iio.w ❑ PARMEASHIP ❑ STATEAGEMN / ❑ COWORATIGN ❑ LOCALAGENC/ ❑ FEDEW.AGENC/ ❑ INOMDUAL ❑ ODINIY AGENCI CITY NAMELY STATE ZIP CODE SITE PHONE p,WITH AREA CODE 'TYPE OF BUSINESS: ❑ 2 DISTRIRIJIOR ❑ 4 PROCESSOR ✓RESBox if INDIAN EPA ID X 1 GAS STATION ❑ 3 FARM ❑ S OTHER TRUSTVLANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE X WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE X WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAIL4G or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE X,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/B..to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE X.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. ❑ I. ❑ 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 k JURISDICTION If AGENCY B FACILITY ID M 11 o/TANKS at SITE 4,3 9 = = I I I / / CURIERT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE X WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 YES E] NO 9 CHECK X PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X BY: V 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 FORM A(3-2-SB) + DATA PROCESSING COPY