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STATE OF CALIFORNIP WATER RESOURCES CONTROL OARD FORM 'A': ; UNDERGROUND STORAGE TANK PROGRAM 4 �a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� v FC_ COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) V FACILITY/SITE NAME CARE OF ADDRESS INFORMATION -R,A . ADDRESS NEAREST CROSS STREET ✓Daxlo intlirsle ❑ PARTNERSHIP ❑ STATE AGENCY r,.f ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY Y`� ❑ INDNIDUAL ❑ COUNTYAGENCY CITY NAME STATEZIP CODE SITE PHONE p,WITH AREA CODE CA 2oq — 51Let TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR '/Box if INDIAN EPA ID n ❑ I GAS STATION X3 FARM ❑ S OTHER TRUSRTYANIDS ON or ❑ ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box toindicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY 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 indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY 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. ❑ 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# At of TANKS at SITE 4 1 zo CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE if WITH AREA CODE o�^ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE LED 3a0 YES ❑ NO 11 q CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT At 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 FORM A(3-2-88) CCC,,, • • DATA PROCESSING COPY