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STATE OF CALIFORNIV WATER RESOURCES CONTRI( RD 3 5 A FORM 'A': UNDERGROUND STORAGE TANK PROGRAM too SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLIC.90N COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ON LY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION LJPERMANENTLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 10 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Gvroindrale ❑IWITHREA ❑ STATE AGENCY N ❑ fAAPtMATIDN ❑ ❑ FEDERAFAGENCY 'A �2� S. I ❑ IND IDUAL ❑ (� CITY NAME STATE ZIP CODE SITE PHOAREA CODE TD 1 CA TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID If RESERVATION or Ka /1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ STEEMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST.FIRST) WITH gREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 4 A MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) I NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE- AGENCY ❑ 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 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE (DP 160 2 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRA T# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ) p')3 r 31 YES ❑ NOtoj/34 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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. FOR (3-2-88) I —cl_c'l DATA PROCESSING COPY