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STATE OF CALIFORNb% WATER RESOURCES CONTROL BOARD FORM'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION G COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE w 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION ✓Box to moli.te ❑ PARTNERSHIP ❑ STATE -AGENCY =AIL. ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY APPROVED BY NAME PHONE If WITH AREA CODE ❑ INDIVIDUAL ❑ COUNTY -AGENCY ADDRESS STATE NEAREST CROSS STREET ✓Roma Mxale ❑ PARTNERSHIP ❑ StATEAGEM,Y LOCjA O CODE (� CENSUS TRACT# SUPERVISOR -DISTRICT CODE ❑ WRF0MT10N ❑ LOCAL-AGENC! ❑ RDUW-A(I I DATE FILED 0_6_8`1 CHECK N PERMIT AMOUNT ❑ INDIVIDUAL ❑ WUIIY4GDlC+ CITY NAME RECEIPT # STATE ZIP CODE SITE PHONE N, WITH AREA CODE I CA TYPE OF BUSINESS: ❑ p D16TRIBUTOR ❑ 4 PROCESSOP ✓ Box if INDIAN EPA ID If Mol 7ANK'6 ❑ 1 GAS STATION ❑ 3 FARM —]5 OTHER RESERVATION TRUST LANDS w ❑/ AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE X WITH AREA CODE DAYS'. NAME (LAST. FIRST) PHONE N WITH AREA CODE NIGHTS: NAME (LAST. FIRST) PHONE M WITH AREA CODE NIGHTS: NAME (I -AST, FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to moli.te ❑ PARTNERSHIP ❑ STATE -AGENCY CURRENT LOCAL AGENCY FACILITY ID N 5 ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY APPROVED BY NAME PHONE If WITH AREA CODE ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE $1. WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boz to iPdicate ❑ PARTNERSHIP ❑ STATE -AGENCY CURRENT LOCAL AGENCY FACILITY ID N 5 Cl CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY APPROVED BY NAME PHONE If WITH AREA CODE ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE IF, 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. ❑ it. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE ANO CORRECT. APPLICANTS NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY X JURISDICTION N AGENCY R FACILITY ID R l V L M of TANKS at SITE I CURRENT LOCAL AGENCY FACILITY ID N 5 APPROVED BY NAME PHONE If WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCjA O CODE (� CENSUS TRACT# SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES NO DATE FILED 0_6_8`1 CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # BY: z I-& N N 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) DATA PROCESSING COPY ri J