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STATE OF CALIFORNIA WATER RESOURCES CONTROL OARD FORM A : UNDERGROUND STORAGE TANK PROGRAM �0 SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 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 01 V I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) t0 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION AD-TEr 4 NEAREST CROSS STREET ✓'w"wale 0 PANT ERSHIP 0 STATE 2 G 0 CORroMTaN ❑ LOCALAGBILY 0 FEDERAL 0 INDIVIDUAL ❑ 03UNTAGENCY CITY NAME STATE DECODE SITE PHONE#.WITH AREA CODE CA TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a If of TANK's 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSRESETVATION LANDS Or ElAT THIS SITE 2 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE H WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Be.to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate Cl PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY 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: 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# IF of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE b WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENS2US3TRACT M SUPE3RVI2OR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED NO CHECKO PERMIT AMO SURCHARGE AMOUNT FEE CODE YES ❑RECEIPT# ❑ 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 ONLY(^ \ FGR (3-2\e) DATA PROCESSING COPY