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STATE OF CALIFORNIA WATER RESOURCES CONTROLB ARD FORM `A': UNDERGROUND STORAGE TANK PROGRAMo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE `"I,sa_"-`" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE 0I ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) W W FACILITY/SITEE CARE OF ADDRESS INFORMATION ,W ADDRES NEAREST CROSS STREET ✓Bub nJkale ❑ PAflTNERSNIP ❑ STATEAGENCY `V ® ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEOERAIAGEND ❑ INoDUAL ❑ COUNTYAGEND CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE CA TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # If of TANK's ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHEfl TRUSTTYLANDS ATION of ❑ 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 NIGHT& NAME(LAST,FIRST) PHONE#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 MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ 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 toindicale ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE If,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. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# ITY ID# #01 TANKS at SITE _ -M = = I L Iq 3 D Li C R NT LOCA AGENCY FACILI,7Y IDX APPROVED BY NAME — ---- PHONE X WITH AREA CODE PERMIT NUMBER U PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# CODE CENSUS TRAC SUPERVISQ$DIST ICT CODE BUSINESS PLAN FILED DATE FILED C, �i YES ❑ NO ❑ IZ PERMIT AMOUNT SURCHARGE A OUNT FEE CODE RECEIPTX BY: T IS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFO kATION ONLY. FLl�OR A(3-2-88) DATA PROCESSING COPY