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STATE OF CALIFORNIA { I 0 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 tip• o z C'911F0 p-�P MARK ONLY ❑ 1 N ERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEMTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY S1TE CLOSURE I FaPILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME I CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS CITY NAME III. TANK OWNER INFORMATION & ADDRESS - INAME MAILING or STREET ADDRESS CITY NAME ✓ Box to indicate ❑ PARTNERSHIP ❑ CORPORATION ❑ LOCAL -AGENCY INDIVIDUAL ❑ COUNTY-AGENC STATE I ZIP CODE BE COMPLETED) CARE OF ADDRESS INFORMATION ✓ Box to indicate ❑ PARTNERSHIP ❑ CORPORATION ❑ LOCAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENC STATE I ZIP CODE ❑ STATE -AGENCY ❑ FEDERAL -AGENCY PHONE #, WITH AREA CODE ❑ STATE -AGENCY ❑ FEDERAL -AGENCY PHONE #. WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (t) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ Il, ❑ III. ❑ THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, APPLICANT'S NAME (PRINTED & SIGNATURE) LOCAL AGENCY USE ONLY DATE COUNTY # JURISDICTION # AGENCY # FAfCILITY ID # # o1 TANKS at SITE r I E] I I i EE 1 VE�H IT I I CURRENT LOCAL AGENCY FACILITY ID # I APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER LOCATION CODE CENSUS TRACT # CHECK # PERMIT AMOUNT PERMIT APPROVAL DATE SUPERVISOR -DISTRICT CODE AMOUNT PERMIT EXPIRATION DATE BUSINESS PLAN FILED DATE FILED YES ❑ NO FEE CODE I RECEIPT # f Y: 1 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 FORM A (3-2-88) 0 DATA PROCESSING COPY