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NTR 't p A 4 NF\\ STATE OF CALIFORNI10 WATER RESOURCES COOARD /� -b FORM `A': �0 UNDERGROUND STORAGE TANK PROGRAM w SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION f�7� COMPLETE THIS FORM FOR EACH FACILITY/SITE ❑ JE 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION MARK ONLY ❑ 7 PERMANENTLY SI ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 1:16 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION FACILITY/SITE NAME ADDRESS NEAREST CROSS STREET ❑✓CORPO�ON Cl 7LOCAL-AGENCY RSHIP AAGEN Y STATE-AGENCYES �� ❑ iNONIMAL Cl GWNTY-AGENCY CITY NAME STATE ZIP CODE I SITE PHONE a.WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box rt INDIAN EPA 10 4 k of TANK s RESERVATION or ❑ AT THIS SITE I OAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) rEMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODENAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODES: NAME(LAST,FIRST) PHONE a WITH AREA CODE I1. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ MAILING or STREET ADDRESS CORPORATION ❑ LOCAL-AGENCY C3 FEDERAL-AGENCY ❑ INDIVIDUAL [03COUNTY-AGENCY STATE ZIP CODE PHONE 0,WITH AREA CODE CITY NAME III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP C] STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE a,WITH AREA CODE CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND 81LLING: I. ❑ II. ❑ 111•❑ 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 FCU - PERMIT JURISDICTION k AGENCY k FACILITY ID k k of TANKS at SITE FT- 1 I �1ENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE ERUMSER' APPROVAL DATE PERMIT EXPIRATION DATE BUSINESS PLAN FILED I DATE FILED E CENSUS TRACT k SUPERVISOR•DISTRICT CODE NO � 3YES ❑PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k Bt: 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. FORMA(3-2-88) e