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STATE OF CALIFORNIR WATER RESOURCES CONTROL BOARD FORM `A': �rF SITE UNDERGROUND STORAGE TANK PROGRAM FACILITY/SITE, INFORMATION �o m INSTRUCTIONS FOR COMPLETING THIS FORM GENERAL INSTRUCTIONS: z 1. One FORM "A" shall be completed for all NEW PERMITS, PERMIT CHANGES or any FACILITY/SITE INFORMATION 1 0 CHANGES. 2. SUBMIT ONLY ONE (1) FORM "A"for a Facility/Site, regardless of the number of tanks located at the site. 3. This form should be completed by either the PERMITAPPLICANT, or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. N 4. Please type or print clearly all requested information. A 5, Use a hard point writing instrument, you are making 3 copies. 00 01 TOP OF FORM: "MARK ONLY ONE ITEM" 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) 1. Record name and address(physical location)of the underground tank(s). NOTE: Address MUST have a valid physical location including city, state,and zip code. P.O. BOX NUMBERS ARE NOT ACCEPTABLE. Include nearest cross street and care of address information if appropriate. 2. Check the appropriate box for TYPE OF BUSINESS. 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP.(ex. CORPORATION, INDIVIDUAL, etc.) 4. If Facitity/Site is located on land within an indian reservation or other indian trust lands, check the box marked "YES'. 5. Phone number must have an area code. If the night number is the same,write "SAME" in proper location. 6. Record the E.P.A. ID N or write "NONE"in the space provided. 7. Indicate the NUMBER of TANKS at this SITE. IL PROPERTY OWNER INFORMATION &ADDRESS-(MUST BE COMPLETED) 1. Complete all items in this section, unless all items are the same as SECTION 1; If the same, write "SAME AS SITE" across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III.TANK OWNER INFORMATION &ADDRESS-(MUST BE COMPLETED) 1. Complete all items in this section, unless all items are the same as SECTION 1; Ifthesame, write"SAME AS SITE"across this section. Be sure to check TANK OWNERSHIP TYPE box. IV. LEGAL NOTIFICATION AND BILLING ADDRESS 1. Check ONE BOX for the address that will be used for BOTH LEGAL and BILLING NOTIFICATIONS. Applicant must sign and date form as Indicated. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY/SITE TO VERIFY THE ACCURACY OF THE INFORMATION. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE"LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS: STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD C/O S.W.E.E.P.S. DATA PROCESSING CENTER P.O.BOX 527 PARAMOUNT,CA 90723 3-1588