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STATE OF CALIFORA WATER RESOURCES CONTROIBOARD ;s`•":c�;'E 1 , W. a FORM A : UNDERGROUND STORAGE TANK PROGRAM �" Z SITE n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ! COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE µ ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 'J I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) cn FACILITY/SITE NAME PCARE OF ADDRESS INFORMATION ADDRESS /I NEAREST CROSS STREET ✓60 to tdiut O PANTNEPSHP ❑ STATE AGENCY ElC ION ❑ LOCAL-AGENCY ClFEDERAL AGENCY �'f/✓Z/ UIVIDUAL ❑ COUNTRAGENCY CITY NAME STATE ZIP CODE E PHONE 4,WITH AREA CODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PRDSSOR ✓Box if INDIAN EPA IDA /Q(^J� ❑ I GASSTATION 3FARM THER RESERVATION or #of TANK's ❑ TRUST LANDS ❑ ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LASI,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE i7 NIGHTS YME(LAST,FIRST) PlHcNE#WITH AREA COOE NIGHTS: NAME(LAST.FIRST) PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,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 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. 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# JURISDICTION R AGENCY M FACIL #of TANKS at SITE I CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT k UPERVISOR-DISTRI T CODE BUSINESS PLAN FILED DATE FILE 22 "'3, YES ❑ NO ❑ / CHECK# 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 INFORMATION ONLY. ` \ FORM A(3-2-88) / V • DATA PROCESSING COPY