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STATE OF CALIFORNIA WATER RESOURCES CONTROLIOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM = " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION b -= COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE IV ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE5 a) ffl I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 0► FACILITY/�LTE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓AMv to MI.* PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION 11 LOCAL EIFEDERAL AGENCY 13INDIVIDUAL ❑ COUNTYAGENCY CITY NAVE STATE ZIP CODE SITE PHONE a.WITH AREA CODE G CA 3I-373 ' TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box i1 INDIAN EPA ID a RESERVATION or #of TANK'# ❑ 1 GAS STATION [:] 3 FARM 5 OTHEfl TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(I-AST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE dwivlq ( 17 IF NIGHTS. NAME(LAST. IRST) PHONE ITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATI N & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE III. TANK OWNER INFORMATION &ADDR S- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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 OR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR , NO TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY •COUNTY# JURISDICTION It AGENCY# FACILITY ID If If of TANKS at SITE ® � � 6 1 1 1 (9 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE E DE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAIz TE F LED Qc- YES NO � �� PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY ATST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. F(�qM A(3-2-88) /: 1 I \�/`NP\ 'STA\ DATA PROCESSING COPY