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Oft• STATE OF CALIFORA WATER RESOURCES CONTE BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION :o c COMPLETE THIS FORM FOR EACH FACILITY/SITE EONLY —1I NEW PERMIT F-1CH3 RENEWAL PERMIT ANGE OF INFORMATION 7 PERMAN TETEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) .I N FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bm Ni le ❑ PMRO W ❑ STATE AGDO rRPMTDN LOCAL-A� ❑ FEDERAL O I�IDUK O LY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box it INDIAN EPA ID N ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS RESERVATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH IR CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ' ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAM[= CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to inoiGate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS w CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ III. ❑ 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 M JURISDICTION N AGENCYAI FACILITY ID N N al TANKS of SITE CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE N WITH AREA CODE z PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LLOCATIONCODE CENSUS TRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEGD Z YES NO 1 e7 M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• B I 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. T� FORMA(9-2-88) . DAlh PROCESSING COPY