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0 • otATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 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 F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E:] 7 PERMANENTLY CLOSED SITE Z ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) C4 CO FACILITY/SI�AME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Butolyduw D PAWNERSHIP D STATE AGENCY � �qq D WRPORATION D LOCALAGENCY D FEDERALAGENCY L/�J . Cl INDIVIDUAL D GOUNIYAGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID p RESERVATION or X of TANK'X E] 1 GAS STATION ❑ 3 FARM E] 5 OTHER TRUST LANDS ElAT 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 N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE X WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATEAGENCY D CORPORATION Cl LOCAL-AGENCY D FEDERALAGENCY Cl INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERALAGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE X,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE 0)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE X WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO t-y- -b CHECK# PERMIT AMO NT SURCHARGE AMOUNT FEE CODE RECEIPT X BY: i THIS FORM MUST BE ACCOMPANIED BYAT LEAS OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION Y,-- ,,F99RM A(3-2-88) ,/,�- ;�0 -CIO DATA PROCESSING COPY J