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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM n" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' IIZO COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT W5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F+ ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) A FACILITY/SITE NAME CARE OFADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓ftth r* D PARMEASIIP D STATE AGBN,Y D COAPOIATEN ❑ LOCAL AGEN D FEMM-AGENCY ❑ INDIVIDWL D CODNttAGENCY CITY NAME STATE ZIP CODE SITE PHONE A.WITH AREA CODE CA TYPE OF BUSINESS: ❑ y DISTRIBlJIOR ❑I PROCESSOR ✓Rox it INDIAN EPA ID a ❑ I OAS STATION ❑3 FARM ❑ 5 OTHER TRUSRESETYLANDS ATION or ❑ A of TAMPI AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING m STREET ADDRESS ✓Box to indicale D PARTNERSHIP D STATE-AGENCY D CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS N/Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CIN NAME STgTE 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. ❑ 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 K JURISDICTION N AGENCY M FACILITY ID# #of TANKS of SITE m CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMB PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ELOCFA�ONCENBUS"ACTH SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATEFILED ' YES NO 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 ON5 LY FORM A(3-2-8B) Y,r.` DATA PROCESSING COPY