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STATE OF CALIFORFW WATER RESOURCES CONTO BOARD q FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION " COMPLETE THIS FORM FOR EACH FA LITY/SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P D SITE ONE ITEM ❑2 INTERIM PERMIT ❑ /AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE _ 1) 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) cn FACILITY/SITE NA ^ CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓SVPm Cl RWTNERSHIP 0 DATE AGENCY 0 WRVRATO Cl LOCAL AGENCY Cl FEOFRAL-AGENCY �f 0 INNOUAL 0 COATY AGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑R PROCESSOR ✓Box J INDIAN EPA ID N ❑ E] ❑ RESERVATION oY ❑ N of TANK'! I GAS STATION 3 FARM 5 OTHER 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 AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING x STREET ADDRESS ✓Boa to imicate 0 PARTNERSHIP 0 STATE AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL AGENCY t ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE I ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION t MAILING or STREET ADDRESS ✓So.to moicale 0 PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION 0 LOCAL AGENCY 0 FEDERAL AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK 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 N JURISDICTION I AGENCY N FACILITY ID N N of TANKS at SITE lyl � I I I / I -'/ / a CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE N WITH AREA CODE r l.1 "�� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT I SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED / U YES NO [] / T CHECKIt PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT) BY: �V THIS FORM MUST BE ACCOMPANIEDBY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OFSIT[INFOR ATION ONL� (nWFORM oA(3-2-BS) v ,/� y� '� � • . DATA PROCESSING COPY •'