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STATE OF CALIFORNIA WATER RESOURCES CONTROLHOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITECO FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMASITE ONE ITEM lil 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE II ACILITY/SITE INFORMATInM s AnnOCCO — time ICT s� FACILITY AME JURISDICTION K NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toinoicate 11 PARTNERSHIP STATE CARE OF ADDRESS INFORMATION -AGENCY ❑ CORPORATION D LOCAL -AGENCY ❑ FEDERAL -AGENCY ADDRESS 7 2(��) NEAREST CROSS STREET ✓Bw airrirale ❑ PARTNERSHIP ❑ STATE AGENCY Cl ZIP CODE PHONE M. WITH AREA CODE CENSUS TRACT# SUPERVISOR -DISTRICT CODE WIPORATION 11 AGEENC ❑ FENRALAGENLY CITY NAME — PERMIT AMOUNT C ❑ COCk ) RECEIPT# STATE ZIP CODE SITE PHONE N, WITH AREA CODE CA TYPE OF BUSINESS: F-1 2 DISTRIBUTOR 4 PROCESSOR ✓ Box it INDIAN EPA ID # I GAS STATION D 3 FARM lil5 OTHER VATION or ❑ # W TANK'# TRUSRESET LANDS AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE N WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — lAAusT RF rnAADI rTrnl Ill. TANK OWNER INFORMATION & ADDRESS — (MUST RF CnSADI FTFni JURISDICTION K NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toinoicate 11 PARTNERSHIP STATE APPROVED BY NAME PHONE # WITH AREA CODE -AGENCY ❑ CORPORATION D LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE M. WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MUST RF CnSADI FTFni IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ 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 N JURISDICTION K NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY APPROVED BY NAME PHONE # WITH AREA CODE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE It, 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. ❑ IL ❑ 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 N JURISDICTION K AGENCY # FACILITY ID # O 10 # of TANKS at SITE CURRENT LOCAL AGENCY FACILITY YYYIID # APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR -DISTRICT CODE BUSINESS PUN FILED YES NO DATE/f�ILED/� CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST ". OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS M A CHANGE OF SITE INFORMATION ONLY. FORM A (3-2-88) %NW DATA PROCESSING COPY 1I S