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lip .4 STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD /y`�`^' F WP. FORM `A': °- � t UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION j COMPLETE THIS FORM FOR EACH FACILITY/SITE Ca[IFO R�l MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATIONPERMANENTLY CLOSED SITE ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE u I. FACILITY/SITE INFOR ATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓BgY.Ieil2ipte ❑ PARTNERSHIP ❑ STATE-AGENCY RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODES TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PR I/Box if INDIAN EPA ID # RESERVATION or #of TANK's ❑ 1 GAS STATION ❑ 3 FARMTHER I TRUST LANDS ❑ 2�f y� AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARYEMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME ST,FIRST) P NE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE -g_ NIGHTS: NAME(LAST, IRST) W6NE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRE - (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 S TE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADD SS INFORMATION MAILING or STREET ADDRESS ✓Box to indica t El PARTNERSHIP ClSTATE-AGENCY ❑ CORPORATI0 ❑ LOCAL-AGENCY E] FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP DE 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 AN ILLING: I. II. ❑ 111. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KN LEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DAT LOCAL AGENCY USE ONLY ` COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAM7:7- _IL�Zl L E PHONE#WI AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE YES ❑ NO ❑ �/oZ CHECK# 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 RM A(3-2-88) 1 DATA PROCESSING COPY