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STATE OF CALIFORNIP WATER RESOURCES CONTROI ARD FORM `A': UNDERGROUND STORAGE TANK PROGRAMA SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ! " vCOMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 14-5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE fV ONE ITEM ❑ S INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �3 v. I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Nob ADDRESS NEAREST CROSS STREET I/B.to indl.le ❑ PARTNERSHIP ❑ STATEAGEND ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUMRAGENCY CITU NAME STATE ZIP CODE SITE PHONE d,WITH AREA CODE CA TYPE OF BUSINESS' ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p ❑ ❑ ❑ TRUSTLANDS ❑ #of TANKI 1 GAS STATION 3FAAM $OTHER ATTHIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE d WITH AREA CODE DAYS: NAMED FIRST) PHONE d WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE d WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS %/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ COHPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE d,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to v,do.te ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE d.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. ❑ 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE Of WITH AREA CODE G PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK DE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED ❑ DATI DD (�j�j�J YES NO /PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPT# 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 ONLY. FORM A(3-2$1TA J/1 DATA PROCESSING COPY \�/-