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STATE OF CALIFORNI WATER RESOURCES CONTRO OARD WP.: FORM `A': _ � "t,m UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �-Fo ,P COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE _4 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE f.s I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 00 CARE OF ADDRESS INFORMATION FAC TY/SI NAME Inc., [I STATE-AGENCY NEAREST CROSS STREET ✓CORPORATION ❑ LOCAL AGENCY ElFEDERAL-AGENCY ADDRESS ❑ INDIVIDUAL Cl COUNTY-AGENCY SSTATE ZIP CODE SITE PHONE It,WITH AREA CODE CITY NAME CA ✓Box if INDIAN EPA ID # #of TANK's TYPE OF BUSINESS ❑ p ISTRIBUTOR ❑ 4 PROCESSOR RESERVATION or AT THIS SITE ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST.FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY STATE ZIP CODE PHONE#,WITH AREA CODE CITY NAME __:j I I11. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE#,WITH AREA CODE CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(7)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NO 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. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) := LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE -31 CURRENT I,��E��!F CILITY ID k APPROVED BY NAME PHONE k WITH AREA CODE /"f L ,fiJ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER PLAN FILED DA FILED ATI N CO LOCDE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS YES NO 3• RECEIPT# BY: CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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. FC'TM A(3-2-88) DATA PROCESSING COPY