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�a STATE OF CALIFORNIV WATER RESOURCES CONTABOARD °"' 'T"F' A FORM `A': UNDERGROUND STORAGE TANK PROGRAM a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -�. o ' COMPLETE THIS FORM FOR EACH FACILITY/SITE `'A�•aa-`" MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE00 9 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) F+ v FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ti ADDRESS NEAREST CROSS STREET ✓SRe to MI ❑ PUTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERk AGENCY ❑ INDIVIDUAL ❑ COUMY-AGBICY CITY NAME STATE 21P CODE SITE PHONE il,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 01STRIBUTOR ❑ 4 PflOCE550fl ✓Box if INDIAN EPA ID a ❑ 111 of TANK's 1 GAS STATION ❑3 FARM ❑ 50THER TRUSRESETYLANDS ATION Or ❑ ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE IX WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE x WITH AREA CODE II. PROPERTY OWNER INFORMATION 8t ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS */Box to indicate ❑ PARTNERSHIP D STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ 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. ❑ II. ❑ If. ❑ 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 R JURISDICTION M AGENCY b FACILITY ID N At of TANKS at SITE m = / / CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE M WITH AREA CODE A/< ,,� 7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK'* DE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It BY: 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFOR4ONLY \V\1JI FORM A(3-2-88) DATA PROCESSING COPY