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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': � '� UNDERGROUND STORAGE TANK PROGRAM mo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ! " COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 30�5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O+ 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N FACILITY/SITE//NAME CARE OF ADDRESS INFORMATION G• ADDRESS Fro p NEAREST CROSS STREET ✓Soxto ln4lcale ❑ PARTNERSHIP ❑ STATE AGENCY 0 o� J+ ❑ CORPORATION ❑ LCCALAGENCY ❑ FEDERAt AGENCY O f ❑ �NDNIDUAL ❑ COUNT AGENCY CITY NAME STATE ZIP CODE SITE PHONE Y,WITH AREA CODE L cA 3�6 TYPE OF BUSINESS'. ISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID Y IF of TANK'S ❑ 1 GAS STATION Ly 3 FARM ❑ 5OTHER TRUSTVATION LANDSO ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME �yX r CARE OF ADDRESS INFORMATION 0 U$ MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE Y,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box talndicale ❑ PARTNERSHIP Cl STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONEY,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. I. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYAT JURISDICTION# AGENCY N If of TANKS at SITE CU NET LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA ODE F PERMIT ROYAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 1W 2 3- b YES NO F-1 CHE K i PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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. FORM A(3-2-88) (J cA✓ DATA PROCESSING COPY