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STATE OF CALIFORNIA WATER RE OF-, SOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION vt COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT lvr5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED S TE ^' ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 Ct. I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) " FA ILITYBITE NAME CARE OFADDRESS INFORMATION 1 S ADDRESS NEAREST CROSS STREET I/8w In inairale ❑ PARTNERSHIP ❑ STAE"AGEND ❑ CORPORATION ❑ LOCAL 11 FEDERAL AGENCY ❑ INDIVIDUAL ElCOUMY"AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR -/Box it INDIAN EPA ID x 1 GAS STATION 3 FARM ❑ 5 OTHER RESERIF of TANK's TRUSTVLANDS ATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET AD DRESS ✓Box to indicate El PARTNERSHIP ElSTATE-AGENCY❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCYT. 11INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE S A- zo Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME 61 CARE OF ADDRESS INFORMATION MAILING or STREET ADDRES ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p.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# FACILITY ID# #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE p WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT p SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED C G.�] YES NO �� CHECK Ar PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTp BY. THIS FORM MU71E ACCOMPANIED BY AT LEAS 1(OR MORE TANK PERMIT FORM 'B'APPLICATION(S), ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. VFORMA 3-2_89y q _ DATA PROCESSING COPY