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STATE OF CALIFORN vk WATER RESOURCES CONTRCL'tOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION w �4 ADDRESS NEAREST CROSS STREET ✓BNroi,dx* 0 PANTNEWIP 0 STATE AGDO 3� C 0 COF MTION 0 LOCAL.AGENC( 0 FEOEPPL.AGDO D INDMI AL 0 COUIrN AGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE iLe CA S TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑/PROCESSOR ✓Box 81NDIAN EPA IDN Mol TANKY ❑ ESE 1 GAS STATION ❑3 FARM ❑5 OTHEfl TRUSTYLANDS ATION Or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE S 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 or STREET ADDRESS ✓Boa to irIftate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 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 ✓Box toieoicate 0 PARTNERSHIP D STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE S,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDIIBBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION k AGENCY M FACILITY ID R If of TANKS N SITE ® = CURRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME PHONE I WITH AREA CODE PERMIT NU B R 6 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CC CENSUS TRACT I SUPERVISORAISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO ❑ 90 CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS M A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88)