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STATE OF CALIFORNIA WATER RESOURCES CONTRO ARD FORM 'A', UNDERGROUND STORAGE TANK PROGRAM 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 PERMANENTLY CLOSE�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 ADDRESS a NEAREST CROSS STREET mm 0 D CDfPOMTNIN Cl POM AGENCY D FEDERAL AGENCYRSHIP El STATE AGENCY �cr rG� D AmrvDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE A,WITH AREA CODE CA TYPE of BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCES30R ✓Box if INDIAN EPA ID N E of TANK's RESERVATION or AT THIS SITE ❑ I GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(VAST,FIRST) PHONE A WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE Of ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bon toindicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERALAGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A.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. 1:1H. ElIII.❑ 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 N rrJURISDI��ION Al AGENCY N FACILITY ID R M of TANKS of SITE J /FIT CA- CURRENT CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ELOCATIONODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS E ED NO ❑ DATE FIL7 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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 ONL . /FORM A(3-2-88)