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FTATE OF CALIFORNIA WATER RESOURCES CONTROMARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ( 1) 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 47) I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NnE CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ADDRESS ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY PERMIT NUM ER NEAREST CROSS STREET I/ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION ❑ LOCAL ❑ [_STATE ZIP CODE PHONE #, WITH AREA CODE CENSUS TRACT # -AGENCY FEDERAL -AGENCY BUSINESS PLAN FILED YES ❑ NO DATE FILED CHECK # PERMIT AMOUNT ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NA [FEE CODE RECEIPT # STATE ZIP CODE SITE PHONE #, WITH AREA CODE CA TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID # E]1 GAS STATION ❑ 3 FARM ❑ 5 OTHER ATION or El of TRUSTRESEVLANDS AT AT THHIS SITE 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 CO E NIGHTS: NAME (LAST, FIRST) PHONE it WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - MUST BE COMPLETED) NAME JURISDICTION # CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY PERMIT NUM ER ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME [_STATE ZIP CODE PHONE #, WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME JURISDICTION # CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY PERMIT NUM ER ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USEDIFOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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 aatt�SITE C -)V0 CURR NT LOCAL AGENCY FACILITY I # APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUM ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT # SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES ❑ NO DATE FILED CHECK # PERMIT AMOUNT SURCHARGE AMOUNT [FEE CODE RECEIPT # BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FORM `B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION NLY. ORM A (3-2-88) 1 so DATA PROCESSING COPY v