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STATE OF CALIFORNIt WATER RESOURCES CONTROL BOARD a s FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o Z ITE INFORMATION and/or PERMIT APPLICATION l o SITE FACILITY/S G COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) I" IP 0 STATE AGENCY FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ft to 0 CORPORATION TION ❑ LOCAbAGENCe ❑ FEDERALAG NCY Cl INDIVIDUAL 0 COUNTY AGENCY STATE ZIP CODE SITE PHONE N,WITH AREA CODE CITY NAME CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSO ✓Box if INDIAN EPA ID If X of TANK'a RESERVATION or ❑ ATTHISSITE ❑ 1 GAS STATION ❑3 FARM R TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: AME(LAST,FIRST) P /HE 4 WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET A ESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY�> /j�7 ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY (/(/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS -/Box to iTdo.te 0 PARTNERSHIP 0 STATEAGENCY ❑ CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It.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. ❑ It. III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY a3 CIA COUNTY R JURISDICTION# AGENCY N FAC k Of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID Or APPROVED BY NAME PHONE N WITH AREA CODE 96 PERMIT NUMBER o PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK* E CENSUS TRACT 11 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 . 0 3 2 YES � NO 0 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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) >� <J DATA PROCESSING COPY