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STATE OF CALIFORNI WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION (n • . COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY Q f NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) i t7w Cq�IFO RN\P ❑ 7 PERMANENTLY CLOSED SITE N CP W FACT TY/SITE NAM CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY # UL—I 1 �n l.J�i/ ❑ INDIVIDUAL ❑ COUNTY -AGENCY ADDRESS STATE NEAREST CROSS STREET ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY PERMIT EXPIRATION DATE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY LOCATION CODE CENSUS TRACT # Own SUPERVISOR -DISTRICT CODE ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME NO ❑ STATE ZIP CODE PERMIT AMOUNT SITE PHONE #, WITH AREA CODE c� # CA BY: - A .. Caa gn' peer ur„ru%uie\ num Cee rure re A ruAueC Al! mrC wCADUATiAu AM V TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID It ❑1 GAS STATION 3 FARM [—]❑ 5 OTHER RESERVATION or TRUST LANDS ❑ FAT 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 # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE If 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 # of TANKS at SITE Co -DI ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY # of TANKS at SITE Co -DI ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, 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. ❑ II. ❑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 # FTF�l JURISDICTION # AGENCY # FACILITY ID # C �- # of TANKS at SITE Co -DI CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT # Own SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES ❑ NO ❑ DATE FI D CHECK # PERMIT AMOUNT SURCHARGE!AMOUNT FEE CODE 7RECEIPT # BY: - A .. Caa gn' peer ur„ru%uie\ num Cee rure re A ruAueC Al! mrC wCADUATiAu AM V ....V . Vll... .nVV. rr I.rrv.w. .r..rr r. �. rr••v• ,�mr..r .�..... �..m.• • �. •.-. � .... �. �....�.-\��. �..�� ...� -� -- �-----_..� �- �-. _ ---- �---------�-- -__- FORM A (3-2-88) DATA PROCESSING COPY