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or STATE OF CALIFORNO WATER RESOURCES CONTS BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE _ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ! ' rdI tJ COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEV*VFIMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I-A' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE / —4 FF-` 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <a FACILITY/SITE NAM CARE OF ADDRESS INFORMATION m QSSO ADDRESS NEAREST CROSS STREET ✓Bar wvwraw ❑ PARTNERSHIP ❑ STATE AGENCY � ❑ COW MTION 11LOCAtAGENC/ 11FENERALAGENC/ v ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE 2IP CODE SITE PHONE N,WITH AREA CODE lvu CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR [__j4 PROCESSOR ✓Box it INDIAN EPA ID p RESERVATION or Mol TANK's ❑ I GASSTATION ❑3 FARM ❑5 OTHER TRUST LANDS ❑ 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 II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to,rd,cale ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 1. III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to iHE¢ate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ 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. ❑ it. ❑ 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 M AGENCY# FACILITY ID# Al of TANKS at SITE LE I I p I /I ;� vI 1 10-1 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE C/ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI D VES NO `I ? CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: ITHIS 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. FF/ORM 3-248) J DATA PROCESSING COPY ({ 000 V