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L ( STATE OF CALIFORNIA WATER RESOURCES CONTROOOARD �II`� ��s . ,•• FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION °; /� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ff45CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q C I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) C FACILITY/ NAME CARE OF ADDRESS INFORMATION ADDRESS j NEAREST CROSS STREET ✓So Wlr0cie ❑ PARTNERSHIP ❑ STATE AGENCY COMITIONoxGECCl FECERx.AGENCYO INDIVIDCl LOCAL CITY NAME / STATE ZIP CODE SITE PHONE#,WITH AREA CODE IV/ CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID N I GASSTATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or ❑ #of TANK's LANDSAT THIS 517E 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 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ 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 A/BOX to indicate Cl PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE !� IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK 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. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYIN JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE c � 3 ..i PERMIT NUMBER PERMIT APPROVAL PERMIT EXPIRATION DATE LOCATI E I CENSUS TRRAJCTr# SUPERVISOWDISTRICT CODE BUSINESS PLAN FILED DATE FILED OI 2 f Gi l VES NO El CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY:x/ 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 Lf✓ FORM( SF) (^� '7 ' • DATA PROCESSING COPY ••