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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD .-'``'°'' " r: Asa FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o r COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE s J I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) OI FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS 1 NEAREST CROSS STREET B.la in .In ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY / ❑ INDIVIDUAL ❑ COUNPIAGENCY CITY NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a RESERVATION or #of TANK's -, E] 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS El AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE a 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 a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ 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 ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ 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. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYIN JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE a � CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE CPL;-? ao PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAT ON CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL D �/ YES NO C' Z�J��J CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It BY: C THIS FORM MUST BE ACCOMPANIED BY AT (1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. RM A(3-2-98) \\ Fl .—L"�� FILE COPY 40U