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STATE OF CALIFORNIP WATER RESOURCES CONTROO16ARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION .a COMPLETE THIS FORM FOR EACH FACILITY/SITE `^�e•oa�`" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 5o I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 9<- ADDRESS /r —Y NEAREST CROSS STREET D PARTNERSNP D STATE-AGENCY 3/ {� 0 CIMPOMTION 0 LOCAL AGENCY 0 FEDERAL AGENCY 0 INOIVIWAL 0 CON AGENCY CITY NAME STATE ZIP CODE SITE PHONE I,WITH AREA CODE CA TYPE OF BUSINESS'. ❑2 DISTRIBUTOR ❑ 1 PROCESSOR I -/Box it INDIAN EPA ID 0 ❑ ❑ ❑ TRUSTATION LANDS m If of TANK's ❑ AT THIS SITE I GAS STATION 3 FAfiM 5 OTHER EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE P 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 o,STREET ADDRESS ✓Box to,.d,cale 0 PARTNERSHIP D STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to md,cale 0 PARTNERSHIP D STATE AGENCY 0 CORPORATION D LOCAL-AGENCY 0 FEDERAL AGENCY 0 INDIVIDUAL D COUNTY-AGENCY 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION M AGENCYA! FACILITY ID B N of TANKS N SITE CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY MAME PHONE F WITH AREA CODE p30 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACTSUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI O 9 2 YES ❑ NO S CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT II I Mass THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11109 MORE TANK PERMIT FORM 'B'APPLICATION(SI, URI Fqq THIS IS A CHANGE OF SITE INFORMATION ON II YIFORM�A(32 SB)