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STATE OF CALIFORNIP WATER RESOURCES CONTRO OARD FORM `A': V ao UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,/ ' so C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE ..5 SITE 00 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FA ITV11SITENAME CARE OF ADDRESS INFORMATION IV ADDRESS ' NEAREST CROSS STREET I/B.11,11I Cl PARTNERSHIP 0 STATE AGENCY Cl CORPORATION 0 LOCAL AGENCI ❑ FEDERAL AGENCY ❑ INDIVIDUAL 0 COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA Z O TYPE OF BUSINESS: ❑ B DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID a P of TANK's ❑ 1 GAS STATION ❑ 3 FARM HER TRUSTVUANDSATION o ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE ft WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE K WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to ic4icale 0 PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,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. p<If ❑ Ill. ❑ 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 M JURISDICTION R AGENCY N FACILITY ID# If of TANKS at SITE Q� ff# PERMIT LAMOUNT APP VED BY NAME PHONE K WITH AREA CODE PPROVAL DATE PE MIT EXPIRATION DATESUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NOE] SURCHARGE AMOUNT FEE CODE RECEIPT M BY: i THISFORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) - DATA PROCESSING COPY.