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STATE OF CALIFORM t WATER RESOURCES CONTROL BO....D FORM `A': UNDERGROUND STORAGE TANK PROGRAM l ALL SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq=p�qN P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE ` Q FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SI NA(M'E�� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS W ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ADDRESS NEAREST CROSS STREET ✓ Boz to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY 1 /� ZIP CODE ❑ CORPORATION ❑ LOCAL -AGENCY ElFEDERAL-AGENCY / c:- �� ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME5—mll STATE ZIP CODE CENSUS TRACT # SITE PHONE #, WITH AREA CODE C�� A.J CA NO ❑ DATE FILED CHECK # TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID a RECEIPT # # of TANK's ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS. NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE 11. PROPERTY 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 CURRENT LOCAL AGENCY FACILITY ID # 1 ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, 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 CURRENT LOCAL AGENCY FACILITY ID # 1 ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, 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. ❑ if. ❑ 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 t nrAl ArFNrV IICF C1N1 V COUNTY # O JURISDICTION # AGENCYL# lFACILITY ID # L# Lof TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID # 1 APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT # SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES ❑ NO ❑ DATE FILED CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # 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. FORM A (3-2-88) Lk-,- DATA PROCESSING COPY 7 �.i N