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STATE OF CALIFORNIA WATER RESOURCES CONTROL OARD .F FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =°° o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT YCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE fV ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) [a FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADD�REySS NEAREST CROSS STREET '/BI 11 PARTNERSHIP ❑ STATE AGENCY X T� 'l ClCORPORATION El LOCAL ❑ FEDERAL AGENCY V 1/ S IJ ❑ INDIVIDUAL 11COUNTY AGENCY CITY NAME STATE ZIP CODE /PETE PH NE#,WITH AREA CODE CA 2 l (p TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑4 PROCESSOfl I ✓Box if INDIAN EPA ID # #of TANK'RESE # ❑ 1 GAS STATION ❑3 FARM ❑-&'OTHER TRUSTYLANDS ATION or 1:1 AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) �7�P NE N^�WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE L1 T NIGHTS: NAME(LAST,FI STI 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 `:�I chard I C MAILING or STREETADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 0d CORPORATION ❑ LOCAL-AGENCY 13FEOERAL-AGENCY 11INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PCO"NSE,#,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITU 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. ❑ 11: 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 IF AGENCY# FACILITY ID IF #of TANKS at SITE CURRENT LOCAL AOENCY F\fCILITY ID# APPRO:!:::AME PHONE#WITH AREA CODE P PERMIT APPROVAL DATE ` PER EXZTTIOMPATE V {-�I r11 ' LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED IrN, ��j j I YES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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. FORMA(3-2-8R) � DATA PROCESSING COPY V