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STATE OF CALIFORNIA WATER RESOURCES CONTRO40ARD ar FORM `A'; UNDERGROUND STORAGE TANK PROGRAM = ,. ° ° SITE Y FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 3 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 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 — . ADDRESS NEAREST CROSS STREET ✓Box to rdicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY -/ ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE 0,WITH AREA CODE t q� CA TYPE OF BUSINESS F—] 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN RESERVATION or EPA ID a ft of TANK'a ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl 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 or STREET ADDRESS ✓Box to indicate ❑i PARTNERSHIP ❑ STATE-AGENCY CI CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOT14 LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. ❑ THIS FORM HAS BEEN COMPLETELY 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE V -- I I I z I I I " CURRENT LOCAL AGENCY FACILITY ID k APPROV D BY NAME PHONE#WITH AREA CODE JFM IT NUMBER PERMIT APPROVAL DATE PERM EXPIRATION DATE TION CODE CENSUS TRACT/k� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO 1:17 K M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p BY: FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. (3-2-88) y� DATA PROCESSING COPY