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STATE OF CALIFORNIT WATER RESOURCES CONTROL BOARD a FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; �4LIFORN�P 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 r I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Q NEAREST CROSS STREET ✓0ORPOEnle 0 PAIUNBGEN 0 STATE-AOENCY ADDRESS ❑ COflP0AAl10N ❑ LOCAL-AGBlCY ❑ FEDERAL AGENCY DI �,f (T — ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME 1 l STATE ZIP CODE SITE PHONE If,WITH AREA CODE CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N If of TANW& RESERVATION or ❑ ATTHIS SITE ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(IAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE It WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indic"e 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 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: I. ❑ if. El III.El 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE O CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE LPERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ODE CENSUSTRACTN SUPERVISOR- I8TRICT CODE BUSINESS PLAN FILED DATE FILEDYNN 3YES NOE PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT BY: % A ( \ n f ` THIS FORM MUST BE ACCOMPANIED BY AT LEAST( R MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. r�� FORM A(3-2-88) OL DATA PROCESSING COPY \