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STATE OF CALIFORNIA WATER RESOURCES CONTROAARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Ef, CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1114 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Cr C I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) �� C FACILITY/ NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓RpvbifAWle D PARTNEASHP D STATE AGENCY D INO��II� Cl LOCAL AGENCY Cl FEDERAL AGENCY CITY NAME STATELP CODE SITE PHONE p,WITH AREA CODE CA TYPE of BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box ii INDIAN EPA ID N ❑ If of TANKs 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS RlONo ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHT$: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION I MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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 ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY D INDIVIDUAL ❑ COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE N,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. ❑ it. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE i LOCAL AGENCY USE ONLY ! COUNTY M JURISDICTION M AGENCY k FACILITY ID If If of TANKS at SITE CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE 1 C �-3 PERMIT NUMBER PERMIT APPROVAL PERMIT EXPIRATION DATE LOCATI E CENSUS TRACTr0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED /� 0� 2 1 2-3, Co YES NO 5 I CSV CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: 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 ONLY. W ;� D �i DATA PROCESSING COPY