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STATE OF CALIFORNI# WATER RESOURCES CONTRC*OARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM µ) SITE P FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION / ; ,c COMPLETE THIS FORM FOR EACH FA ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P $ $ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE U f-A I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) U-I FACILITY/SITE NAME), CARE OF ADDRESS INFORMATION ADDRESS �/ NEAREST CROSS STREET ✓(I.Wix'ae ❑ PAAIMASNP ❑ STATE AGENCY Cl GOTIOMTDN ❑ LOCXAGENCY ❑ FEOEPALAGENCY D ❑ INOMMAL Cl COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE A.WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p RESERVATION or N of TANK's ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS. NAME(LAST,FIRST) PHONE 1 WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box Io inoicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY Cl FEDERAL-AGENCY Cl INOWIDUAL ❑ COUNTYAGENCY CITY NAME STATE 21P CODE PHONE x.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to meicale Cl PARTNERSHIP ❑ STATE-AGENCY 0 CORPORATION ❑ LOCAL AGENCY ❑ 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)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(POINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY 1 FACILITY ID 1 k of TANKS at SITE CURRENT LOCAL AGENCY FACILITY 101 APPROVED BY NAME PHONE N WITH AREA CODE C�V PERMIT NUMBER PERMIT APPROVAL DATE PERMIT UPIRATION DATE '] LLOCATnIONCOOE CENSUS TRACT 1 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEDYES NOEPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 1 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(3-2-88) L" DATA PROCESSING COPY