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STATE OF CALIFORN• WATER RESOURCES CONTROL BOARD FORM 'A': - UNDERGROUND STORAGE TANK PROGRAM SITE _ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMAN D SITE li ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / '" I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) co FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓BW INUNuk D PARTNEMIP D STATE AGENCY Cl COPWRATION I] LOCAL AGENCY D FEOEPAL AGENCY D INDIVIDUAL Cl COUNTYAGENU CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR I ✓Box if INDIAN EPA ID N RESEE] 1 GAS STATION 3 FARM ❑ 5 OTHER TRUSTYATIf THIS LANDS ATION or ❑ SI AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to I.d,cale D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCALAGENCYD FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boz 10 indicate ❑ PARTNERSHIP ❑ STATE-AGENCY D CORPORATION Cl LOCAL AGENCY D FEDERALAGENCY D INDIVIDUAL Cl 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 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 APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N �AIIGENCY N '' FACILITY 10 N N of TAPI at SITE L� CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE L G- 90 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINES,PLAN OFILED NO ❑ DIJTEFILE CNECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT LLB ' n /I THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), USS THIS IS A CHANGE OF SITE INFORMATION ONLY. � FORMA(3-2-88) • 2L/k� DATA PROCESSING COPY