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yE�O F 1 STATE OF CALIFORNIA WATER RESOURCES CONTR OARD `A': no FORM UNDERGROUND STORAGE TANK PROGRAM o SITE ///// FACILITY/SITE, INFORMATION and/o PERMIT APPLICATION ,- C'a LIFO P��P COMPLETE THIS FORM FOR EAC 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 I. FACILITY/SITE INFORMATION & ADDRESS - (MUSK BE COMPLETED) FACILITY/SITV,gAME CARE OF ADDRESS INFORMATION NEAREST CROSS STREET ✓Box to indicate Cl PARTNERSHIP ❑ STATE AGENCY ADDRESS ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY � Cl INDIVIDUAL COU NTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA 207- TYPE OF BE S: 2 TRIBUTOR ❑ 4 PRO SSOR *w/Box if INDIAN EPA ID a M of TANK's RESERVATION or AT THIS SITE ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) i 11. PROPERTY OWNER INFORMATION &ADDRESS -I(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE N,WITH AREA CODE CITY NAME III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE 11,WITH AREA CODE CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR 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. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION k AGENCY# FACILITY ID 8 M of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID k ==APPR=OVEDY NAME PHONE K WITH A CODE C L I..F PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIO ODE CENSUSTRACT SUPESSR-(STRICT CODE BUSINESS PLAN FILED DATE FIL D 3 YES ❑ NO ❑ RECEIPT K B CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE THIS FORM MUST BE ACCOMPANIED BY AT LEAST OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-68)