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�0 STATE OF CALIFORNIAWATER RESOURCES CONTROAARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ~ ' SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION � ® C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE N ME CARE OF ADDRESS INFORMATION ADDRESS - I NEAREST CROSS STREET ✓3"Maki CI PARTNERSHIP 11STATE AGENCY �� (//(,J, ❑ CORPORA ION ClLOCX AGENCY ❑ FEDERAL AGENCY ❑ INDNIOUAL 0 COUNTY AGENCY CITY NAME S� STATE ZIP CODE SITE PHONE 4 WITH AREA CODE J CA Sa TYPE OF BUSINESS. F—] 2 DISTRIBUTOR F—] 4 PROCESSOR ✓Box if INDIAN EPA ID N ESE1 GAS STATION ❑ 3 FARM El OTHER TRUSTVLANDS ATION or ElAof HIS SITE AT THIS STE 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 a WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & DDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS - ( UST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCALAGENCYCl FEDERALAGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING , DDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH EGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND T THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY B FACILITY ID W Mol TANKS at SITE = = = 1010le-4315- 1711610101o] CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE e o PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOC ?ION ODS CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATEFI D p� a p�a YES NO CH K• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 ONL' FORM A(3-2-88)