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STATE OF CALIFORNI* WATER RESOURCES CONTROL�OARD i u FORM 'A': �, > ' , , UNDERGROUND STORAGE TANK PROGRAM .o 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 ❑ / AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bwnrann ❑ PAATNERSIR ❑ STATE AGENCY ❑ DONCRATON ❑ WMAGENCY CIfEDEWAGENC! ❑ INEwaG. ❑ 00UM AGENCY CITY NAME STATE ZIP CODE_ SITE PHONE A.WITH AREA CODE f CA - y'G/ TYPE OF BUSINESS: ❑ 2015TRBUT011 ❑ 1 PROCESSOR I ✓Box if INDIAN EPA ID N NOI TANK4 ❑ I GAS STATION ❑ B FARM ❑ 5 OTHER TRUSTYLANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRSTI 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(UST.FIRST) PHONE N WITH AREA CODE IL PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to iw1cale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION 8 ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to mdwale O PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY 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: I. ❑ if. ❑ 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 S JURISDICTION S AGENCY S FACILITY IO S A'of TANKS Al SITE CURRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME PHONE N WITH AREA CODE ` All PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACTS SUPERVISOLA R•DISTRICT CODE BUSINESS PN FILED DATE FILED YES E) NO ❑ y(— 74 CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTS 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. .. -� 1 �FORMA(3-2-BS) •