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STATE OF CALIFORNIP WATER RESOURCES CONTROLB ARD FORM `A': '. UNDERGROUND STORAGE TANK PROGRAM =" o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION b ; OeCOMPLETE THIS FORM FOR EACH CILITY/SITE `"�•�e�`" y MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE Lj ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5✓ �0 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME _ CARE OF ADDRESS INFORMATION f� AD ESS NEAREST CROSS STREET ✓Bo.10M ale CI PARTNERSHIP ❑ STATEAGENC/ 0.V ❑ (CORPORATION 0 LOCAL AGENCY ❑ FEDEIIAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY N E STATE ZIP ODE SITE PHO E N,WITH AREA CODE CA �SZO C TYPE OF BUSINESS: F-1 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N ESE❑ I GASSTATION ❑3 FARM ❑ 5 OTHER TRUSTY LANDS ATION o ❑ A7 HIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toin6icate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a.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. ❑ 11. ❑ 111. ❑ 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 a JURISDICTION R AGENCY a FACILITY ID If a of TANKS at SITE 3l I I I Z= CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED p�3,Sb31/ YES NO 3 CHECK a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAS OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. , FORM A(3-2-158) -a-C)/ DATA PROCESSING COPY