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STATE OF CALBFORN@ ,.- WATER RESOURCES CONTRO-BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM zVTE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -.m ;, ! ' 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE °.11Foe MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F-a ONE ITEM ❑2 INTERIM PERMIT El4 AMENDED PERMIT E]6 TEMPORARY SITE CLOSURE 00 D0 I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) F-� FACILI SITE NAME CARE OF ADDRESS INFORMATION Nub 0 ) ADDRESS D NEAREST CROSS STREET ✓Box tor&& ❑ PARTNERSiNP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME/-. STATE ZIP CODE SITE PHONE Jr.WITH AREA CODE CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N ESER❑ 1 GAS STATION ❑3 FARM ❑5 OTHER TRUSTVLANDS ATION�I ❑ —TAT THIS SITE 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 ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAMESTATEZIP 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 ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE Id. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION If AGENCY# FACILITY ID M M of TANKS at SITE = 9 CUR "T LOCAL AGENC FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE (�I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAPPIN CODE CENSUS TRACT.# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3. YES NO CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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) �`� DATA PROCESSING COPY �y�aJ