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STATE OF CALIFOSIA WATER RESOURCES COOL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM V SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ;/ to COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE f-1 ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE —I 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NA � CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓BW isle ❑ PARTNERSHIP ❑ STATEAGENCY C- ❑ POAATION ❑ LOCALAGENCY ❑ FEGRIAL AGENCY .J INOMOUAL ❑ COUNTKAGENLY CITY NAME / STATE ZIP ODE SITE PHONE ft,WITH AREA CODE O��✓ CA TYPE OF BUSINESS. ❑ ISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p ❑ I GAS STATION 3FARM 5OTHER RESERVATION or if TANK's j ❑ TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE I 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 C MAILING or STREET ADDRESS ✓Box to'od,cale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY 11 INDIVIDUAL CICOUNTY-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. V it. ❑ 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 Of Is of TANKS at SITE M = = 1 1 14101 ► g CURRENT LOCAENCYFACILITY ID#_ APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER ]CPERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CERACT k� SUPERVISOR-DISTRICT CODE BUSINESSfEs N FILED NO ❑ DATE ED / 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 IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) 6 DATA PROCESSING COPY