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STATE OF CALIFORNIR WATER RESOURCES CONTABOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; COMPLETE THIS FORM FOR EACH FACILITY/SITE <�ropy`P MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CID" I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W CD FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 7 ADDRESS NEAREST CROSS STREET ✓130lardiale ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNIYAGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CSCALLII CA TYPE OF BUSINESS: F-] p DISTRIBUTOR F__] 4 PROCESSOR ✓BO%iI INDIAN EPA ID x ❑ 1 GASSTATION � 2f1RiM ❑ 5OTHER TRUSTESERYLANDS ATION O ❑ ATTHIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA_CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS Be.✓ to indicate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE it.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 ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE ft.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE 11)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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS BI SITE E= CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# DE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED G YES � NO —6 _6 -gj / 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 IN ORMATION ON FORM-A,(3-2-88) • ^ \'Y• ` DATA PROCESSING COPY