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w. - . I - STATE OF CALIFORNIX WATER RESOURCES CONTROCBOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM e _" o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION _,m o COMPLETE THIS FORM FOR EACH FACILITY/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 J/3 I. FACILITY/SITE INFORMATION & ADDRESS-(MUST BE COMPLETED) 'A cv FACILITY/SRE NAM CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bmou4nRe D PAIMOSHIP 17 STATE KOD D COR'CMIION D LOMAGENLY D FEDUKAGENCY ❑ IIUMDIAL D COUNTY-AGENCY CITY NAM STATE ZIP CODE SITE PHONE R,WITH AREA CODE CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box N INDIAN EPA ID N Rol TANKS El1 GAS STATION [D3 FARM ❑ 5 OTHER TRUSTYLANDS DT ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST.FIRST) PHONE R WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE R WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE R WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boz to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D 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 MAIUNG ar STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D 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 b SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY ID R R of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID M APP VEO BY NAME n PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXOIRATIOXDATE LOCATION CODE CENSUS TRACT R SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO ❑ CHECK x PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 J FORMA(3-2-88) � .� DATA PROCESSING COPY