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STATE OF CALIFORNIA* WATER RESOURCES CONTROLOPOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION / LJ COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Ff 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Im I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/ NAME ^ CARE OF ADDRESS INFORMATION O `. ADDRESS NEAREST CROSS STREET ✓Bm to indAaN CIPARTNERSHIP ❑ STATE AGENCY _ -7 ❑ CORPORATION 0 LOCAL-AGENCY 0 EEDERALAGNeY ❑ INDIVIDUAL El COUNW AGENCY CITU NAME , / STATE ZIP CODE (_vJ SITE PHONE p,WITH AREA CODE CA TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓ ❑ ❑ B0x i'INDIAN EPA ID a ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS ATION or ❑ #of AT THHISIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY❑ INDIVIDUAL 0 COUNTYAGENCYCITU NAME STATE ZIP CODE PHONE p,WITH AREACODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS %/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY CIN NAME 11INDIVIDUAL 0 COUNTY-AGENCY STATE ZIP CODE PHONE a,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. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID At #of TANKS at SITE EEEEEP CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE p WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL PERMIT EXPIRATION DATE LOCgTI E CENSUSST2ACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED S CNECKp �� PERMIT AMOUNT SURCHARGE AMO FEE CODE YES ❑RECEIPT NO ❑ By; �J �� 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), LIN L SS THIS IS A CHANGE OF SITE INFORMATION ONLY (f✓ FOR DATA PROCESSING COPY