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STATE OF CALIFORNIX WATER RESOURCES CONTROL BOARD y ;\ FORM 'A': UNDERGROUND STORAGE TANK PROGRAM '" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 7 j 1 COMPLETE THIS FORM FOR EACH FACILITY/SITE _ MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTItCLLOSED SITE ONE ITEM ❑Z INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ,7�� F � I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) w FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Ln ADDRESS _ NEAREST CROSS STREET ❑ RMTNERSHIP 0 STATE AGENCY f Cl C0PBMT0N 0 LOCA.AGENCY Cl FEDRIAI AGENCY 0 WDIVIDWl 0 CGUNRAGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR F_/V4 PROCESSOR '/Box it INDIAN EPA ID N ❑ SEVATION 1 GAS STATION E]3 FARM 5 OTHER TRUST LANDS or ❑ Nof TANKS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N 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 ✓Bax to indicate ❑ PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ 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.,STREET ADDRESS ✓Box t.,mcate 0 PARTNERSHIP 0 STATE-AGENCY Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE 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: 1. ❑ II. ❑ 111.❑ 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 COUNTY11, JURISDICTION N AGENCY R II��II FACILITY ID N If of TANKS el SITE m u - 1 CURRENT LOCAL AGENCY FACILITY ID 9 APPROVED BY NAME PHONE#WITH AREA CODE � / PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK DE CENSUS TRACT I SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO �U J PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Y 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 ONL FORM A(3-2-86) - V\ DATA PROCESSING COPY \� V