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STATE OF CALIFORNI9 WATER RESOURCES CONTRABOARD FORM `A': a�'�. .. UNDERGROUND STORAGE TANK PROGRAM S!T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN LY CLOSED SITE I"A' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 N I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) A CD FACILI /SITE NAME CARE OF ADDRESS INFORMATION ADDRESS ('� NEAREST CROSS STREET ✓D Ib irdirale ❑ PARTNERSHIP ❑ STATE AGENCY J ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL s Cl INDIVIDUAL ❑ 001 CITY NAGE STATE ZIP ODE SITE PHONE X,WITH AREA CODE `J' CA TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 Pq ESWR ✓RFSBox if INDIAN EPA ID # ❑ I GAS STATION ❑ 3 FARM OTHER TRUSTVLANDS o ❑ N of TANK'X AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS. NAME(I-AST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE X WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION NGMAILG or STREET ADDRESS ✓Box to iftcate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE X,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box tolndicate ❑ PARTNERSHIP ❑ STATE-AGENCY O CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ 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 10101d,13= 0000 CURRENT LO AL AGENCY FACILITY IDX APPROVED BY NAME PRONE N WITH AREA CODE P. l s O PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CO CENSUS TRACT SUPER111701711CT CODE BUSINES,PUN❑FILED NO DATE FILED CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: t 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 ON /rORM A(3-2-88) DATA PROCESSING COPY 0