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STATE OF CALIFORNIP WATER RESOURCES CONTROPIOARD a FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMITCHANGE OF INFORMATION ❑ 7 S/ Y CLOSED S1TE ONE ITEM E] p INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE b / I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) FACILITY/SITE NAM hh,�, p CARE OF ADDRESS INFORMATION NAT � �l 4/M 0 /C/ ADDRESS / �� NEAREST CROSS STREET ✓ rah Bmloirti0 PAHTNERSYIP 0 STATE AGENCY Z \ / Cl CORPORATION 0 LOC,LAGENCI' 0 FEDEMAGENCY ❑ INDMDUAL 0 COUMYAGENCY CITY NAME STATE ZIP COCj. SITE ONE N.WITH AREA CODE CA TYPE OF BUSINESS: 0 Z ISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID RESERVATION or X#1 HIS SI ❑ I GAB STATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY C NTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(IAST,FIRST) PHONE#WITH AREA 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 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY Cl INDIVIDUAL 0 COUNTYAGENCY 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 ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERALAGENCY 0 INDIVIDUAL Cl 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: 1. ❑ 11. ❑ 111. ❑ 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) GATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION M AGENCY M FACILITY ID# B of TANKS N SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE I PERMIT NUi BER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIO E CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED NO ❑ DATE FILED CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: � 5 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 �� �RIM A(3-2-88) • •