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STATE OF CALIFORNIP WATER RESOURCES CONTROO- dOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION } IB 1 COMPLETE THIS FORM FOR EACH FACILITY/SITE "1110 ay`% MARK ONLY [__jFA I NEWRMIT ❑ —>• 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE } ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE F � I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) w FACILITY/S"FTE NAMECTI CARE OF ADDRESS INFORMATION U ADDRESS /I� NEAREST CROSS STREET ✓Box com mm952 AGENCY 0 SUIT AGENEN 0 CONPONN ❑ FEOEPN AGENGY ❑ INGIV10UCOUNTYNCY CITY NAME STATE ZIP CODE H AREA CODE CA TYPE OF BUSINESS: ❑p DISTRI OR ❑/PIWCESSOR ✓Box it INDIAN EPA ID p M of TANK'Y 1 GAS STATION ❑3 FARM 5 OTHER TRUSTMLA IOS or ❑ AT THIS SITE EMERGENCY CONTACT PERS (PRIMARY) EMERGENCY CONTACT PERSON(SECONDAR ) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PM NEN ITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) ONE WITH AREA CODE n TO IL PROPERTY OWNER INFORMATIO & ADDRESS— (MUST BE COP TE ) NAME CARE OF ADDRES INFO ATICN MAILING or STREET ADDRESS ✓BoxloieJic 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORA0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to m,cale ❑ PARTNERSHIP 0 STATEAGENCY 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTYAGENCY 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 EGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND T HE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(POINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY,/—Y JURISDICTION IY AGENCYIT FACILITY R F of TANKS at SITE CURRENT LO AGENCY F LITY ID Y APP VED BY NAME PHONE N WITH AREA CODE PE MIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DAT LOC ION CODE CENBUS TRACT Y SUP R•DISTRICT CODE BUSINESS PLAN FILED DATE IN D YES ❑ NO ' 9 CHECK Y PER YOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHAIGfi OF SITE INFORMATION ONLY. FORMA(3-2-88f : DATA PROCESSING COPY }