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STATE OF CALIFORNI.0 WATER RESOURCES CONTROOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I 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) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION l - 6as ADDRESS NEAREST CROSS STREET ✓Bminmkale D PNTNDEHIP D STATE-A000 D MV M4PON D LOCk AGENCY D fE➢DUL-AWO /fib Cl INDIVIDUAL ❑ ODUNIY.AGBICY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE Is CA ?U`� TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Boz if INDIAN EPA ID N RESERVATION dr R of TANK'N ❑ 1 GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS ❑ AT THIS SITE s 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 N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bortoindioale D PARTNERSHIP ❑ STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE N,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: 1. ❑ It. ❑ 111. ❑ 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 M AGENCY N FACILITY ID N N of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUM8E PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED 0 2 • O o 3{14;_ YES [:] NO [_] ^ O CHECK# PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BYi,p THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE`ININFORMATION ONLY, � 1/ FORM A(3-2-88)