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S 1 A I t OF GALIFUHNIJO WATER RESOURCES CONTRO&ARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SIT /� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANE LY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPOflARY SITE CLOSURE S/ IO 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITYITE NAME CARE OF ADDRESS INFORMATION v fbOR \ NEAREST CROSS STREET ✓embwk ❑ FARTIERSHIP ❑ STATE GUYCO ❑ WNONAi10N O LOGLAZE1Y Cl FEDRAL-AGENCY1OS� S N ❑ INDR UAL D COUNTY AGENCY STATE ZIPCODE SITE PHONE A.WITH AREA CODE CA �l1 TYPE Of BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOfl Box,f INDIAN EPA ID p RESERVATION or N of TANK'A I GAB STATION ❑ 3FARM ❑ SOTMER TRUSTLANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE A 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 A WITH AREA CODE H. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 1 MAILING or STREET ADDRESS ✓Boa Io ir0cale D PARTNERSHIP D STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP COOE PHONE A.WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to iwicate D PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A.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: 1. ❑ 11. ❑ 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 k JURISDICTION N AGENCY N v FACILITY IDN N of TANKS at SITE L= 100 1 _ZEj= CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE A WITH AREA CODE V k) O PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPMIATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS WAN FILED DATE F ED YES ❑ NO C 'v CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT F BY: i S FORM MUST BE ACCOMPANIED BY AT LEAST(1)ORMORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANCE OF SITE INFORMATION ONLY. FORM (3-2-88) I DATA PROCESSING COPY f