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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD F FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 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 ~ I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) OC FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Box tomilicale ❑ PARTNERSHIP Cl STATE-AGENCY C3CORPORATION ElLOCAL-AGENCYElFEDERAL AGENCY Com-Iry L,-;, Mf / ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE 11.WITH AREA CODE X1'1 CA �6 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID # ❑ ❑ ❑ TRUSTLANDS or ❑ #of TANK'# 1 GAS STATION 3 FARM 5 OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ElSTATE-AGENCYEl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE it,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 ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,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. 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# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE = I I I I I I I I I I F�l z I I /)I n�:� CURRENT LOCAL AGWY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE '5 li.1Z / 3� T PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT#77 SUPERVISOR-DISTRICT E BUSINESS�(] PLAN FILED ❑ DATE FILED v YES NO 44 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: /^J v v THIS FORM MUST�ACCOWANIED BY AT LEASOOR MORE TANK PERMIT FORM 'B'APPLICATION(S), SS THIS IS A CHANGE OF SITE INFORMATION ONLY. S FORM A(3-2-88)V '0DATA PROCESSING COPY 1."