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STATE OF CALIFORNIA WATER RESOURCES CONTROAARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM o z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —, OD 0 I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) —4 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION - /(- NEAREST CROSS STREET ✓E mmate ❑ P AGEIP Cl STATE AGENCY ADDRESS CORPOPATION OCAINCY 0 FEDERN-AGENCY 7 /I 0 INDIVIDUAL ❑ COUNTY AGENCY CITY NAME C/ STATE ZIP CODE SITE HONE p,WITH AREA CODE CA EPA ID p If TYPE OF BUSINESS ❑ 2 DISTRFARM B ❑ 4 OTHERPROCESSOR Box if INDIAN RESERVATION or - AT TANK'HIS SITE ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE o EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS' NAME(LT. EAASFIRST) PHONE N WITH ARCODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 1-1STATE-AGENCY ❑ CORPORATION 0 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 to iocloate 0 PARTNERSHIP 0 STATEAGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CIN 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: I. ❑ it. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION K AGENCY M FACILITY ID% N of TANKS at SITE G y CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE K WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE D. YES NO CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If Y: 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 0 LY. FORMA(3-2-BB) DATA PROCESSING COPY