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STATE OF CALIFORNIX WATER RESOURCES CONTROL o.`..E SEPI r �N FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V �o 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 IV ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE QY @7 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION C ADDRESS NEAREST CROSS STREET ✓Bmbwmi 0 PARTNERSHIP ❑ STATE AGENCY E- I ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY G I`J ❑ INDNIDUAL ❑ COUNTY-AGENCY CITU NAME I STATE ZIP CODE TE ONE#,WITH AREA CODE L-E`J CA N TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID N ❑ 1 GASSTATION ❑ 3 FARM ©5 OTHER TRUST YLANDS ATION of ❑ ATT IS SITE O 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 II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILINGOFSTREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY Tk�_ UM ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAMg. STATE ZIP CODE P ONE 0,WITH AREA CODE z -S III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION /uU �— MAILINGorSTREETADDRESS ✓Box to inoicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID# #o/TANKS at SITE GURRENT LOCAL AGENCY FACILITY ID# AP -`-' -- PHONE M WITH AREA CODE PERMIT NUMBER MIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED Z � YES [] NO r)) `�n c) 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 A CHANGE OF SITE INFORMATION ONLY, FORM A(3-2-88) 6 DATA PROCESSING COPY