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STATE OF CALIFORNMrr WATER RESOURCES CONTROeBOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ff 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 8 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) v h& FACILITY/SI NAME CARE OF ADDRESS INFORMATION /U ADDRESS NRROSS STREET ✓Boxbngitele ❑ PARTNERSHIP ❑ STATE-AGENCY O CORPORATION N ❑ LOCAL ❑ FEDERALAGENCY❑ INCMDUAL ❑ COUNn-AGENCY CITY NAME STATE ZIP CODE HON p,WITH AREA CODE CA %J� S- - TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or 1:1 - K of TANK'N TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST.FIRST( PHONE it WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE a WITH AREA CODE II. 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 ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP O STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE a,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. ❑ if. ❑ 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 N JURISDICTION N AGENCY R FACILITY ID N N of TANKS BI SITE = = = I I 1 / 3 CURRE LOCAL AGENCY FACILITY ID N APPRqV§0 BY NAME - PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE JCHECK CATION CODE CENSUSTRAcC/TN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL a 3 b 3 YES NO � N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: HIS 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./M A(3-2-88) DATA PROCESSING COPY + 5