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STATE OF CALIFORNIA WATER RESOURCES CONTROLOARD i�z FORM `A': UNDERGROUND STORAGE TANK PROGRAM � �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ;/ �'�IIFOPN�N COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERM Y LOSER SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ❑✓W O N O PWNMWYP C3 FTFDERLL EAS L 0 NiI0 O MfY AGEN9 CITY NAME) STATE ZIP CODE SITE PHONE 0.WITH AREA CODE L K�-CJYV CA TYPE OF BUSINESS: EPA ID N ❑ 2 DISiflIBUTOR ❑d P ESSOR ✓Box if INDIAN _ N of TANK'F OTHER RESERVATION or AT THIS SITE ❑ 1 GAS STATION ❑3 FARM _. TRUST LANDS ❑ Ll 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 N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMAT N & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRE - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL ❑ 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 TH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III.F1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AN 0 THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION x AGENCY M FACILITY IDM Not TANKS at SITE " do 73 6R D CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIO CODE CENSUS TIL, _0 BUPERVI30 9TR CODE BUSINESS PLAN FILEDNO ❑ DATELED YES E] ` CHE F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N Ya \ 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. \v�,1 FORM A(3-2-88) • • • c