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STATE OF CALIFORNIA WATER RESOURCES CONTROLBOARD EPa Jif FORM A': UNDERGROUND STORAGE TANK PROGRAM �a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Clx COMPLETE THIS FORM FOR EACH FACILITY/SITE 'IFS MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT FV 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 7..4 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT n 6 TEMPORARY SITE CLOSURE a I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CO FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 1 u� ADDRESS NEAREST CROSS STREET ✓Dam to iatlifale Cl PARTNERSHIP ❑ STATE AGENCY r _ ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY R ( IA H 01> ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE S E PHONE#,WITH AREA CODE CA -ZC7 Z TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a RESERVATION or #of TANMa O ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS AT TN 1:1IS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE Y NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(IAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS A/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION i MAILING or STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCYCl FEDERALAGENCY ❑ INDIVIDUAL ❑ 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. ❑ IL ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID# #o1 TANKS at SITE ffE = = I I I 1 2 r O CURRENT LOCAL AGENCY FACILITY ID Or APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# ODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED 4 2— YES ❑ NO �' �L O 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. 1 FORMA(3-2-88) W ` ` A(\ , �{ • DATA PROCESSING COPY