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OF ., STATE OF CALIFORA WATER RESOURCES CONTR BOARD ; FORM 'A': UNDERGROUND STORAGE TANK PROGRAM � no SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C'q IIFfl A r-1 COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA NTL�CLOSEC SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SI AME i CARE OF ADDRESS INFORMATION �{,e Lir NEAREST CROSS STREET ✓Box ieale to r ❑ PARTNERSHIP ❑ STATE AGENCY ADDRESS ,pC ❑ CpppgRATION ElLOChL-AGENCY ❑ FEDERAL-AGENCY /}�,� Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE CA TYPE DE BUSINESS: ❑ 2 DISTRIBUTOR El4 PROCESSOR �B RVATION Dr iINDIAN EPA ID # - #of TANK'S 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE -} EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE Al WITH AREA CODE NIGHTS; NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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 indicate 1:1 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 ADO111Et119 SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ III.❑ THIS FORM HAS SEEN 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# #of TANKS at SITE Ell] 1 1 1 j F-7 CURRENT LOCAL AGENCY FACILITY IDK APPROVED BY NAME PHONE K WITH AREA CODE C PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION GDDE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED NO ❑ DAD 2 � CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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", 1 FORMA(3-2-88) � .