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STATE OF CALIFORNIP WATER RESOURCESCONTROROARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITEn FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 44 /'T COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓BoobMm ❑ PARTNERSHIP ❑ STATEAGENCY ❑ COAPOMTION Cl LOCAL AGENCY Cl FEDERAL AGENCY • 0 INDMDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE CA TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESS0 ✓Box iT INDIAN EPA l0 x ❑ ❑ ❑ If of TANKs AT TRUSTYLANDS ATION or ❑ AT THIS SITE I GAS STATION 3 FARM 5 OTHER EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH ARFA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. 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 ❑ INDIVIDUAL O 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 m indicate ❑ PARTNERSHIP Cl STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ 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. ❑ II. ❑ Ill.❑ 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 R AGENCY N FACILITY ID R R of TANKS BI SITE [9� I I I I I I I I I I ]at CURRENT LOCAL AGENCY FACILITYJD# APPROVED BY NAME PHONE N WITH AREA CODE I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [CHECK OCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO sp—'2'K,5d N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN 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 INFO MATIONIONLY, FORMA(3-2-88) • •