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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE / // �{ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ��-� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 7 FVIMANICLOSEDSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E:]6 TEMPORARY SITE CLOSURE%G 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACIUNAMECARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ADDRESS NEAREST CROSS STREET ✓&. t. eliale ❑ MRiNERSHIP ❑ STATE -AGENCY ❑ CARPIOHALION O U)CALAGENCY ❑ FEDERAL -AGENCY El INDIVIDUAL COUNIYAGENCY CITY NAME C w/ STATE CA ZIP CODE SITE PHONE #, WITH AREA CODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4PflOCES50R ❑ I GAS STATION ❑ 3 FARM ❑ S OTHER Box if RESERVATION or TRUST LANDS ❑ EPA ID x PERMIT EXPIRATION DATE # M TANK'# 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 # WITH AREA CODE NIGHTS: NAME (LAST. FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Be. to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY IF of TANKS at SITE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #. WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY IF of TANKS at SITE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CIN 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. ❑ it. ❑ 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 # m JURISDICTION # = AGENCY # = FACILITY ID # 1ej0 17 IF of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES ❑ NO DATE FILE CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# B THIS FORM MUST BE ACCOMPANIED BY AT LEAST Itt OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY FORM A (3-2-81G, A✓ �' DATA PROCESSING COPY