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• of p, STATE OF CALIFORNIA WATER RESOURCES CONTROL BARD A FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION G COMPLETE THIS FORM FOR EACH FACILITY/SITE ❑7 PERMANENTLY CLO D SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ITS CHANGE OF INFORMATION I ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT L�—fl-6 TEMPOflARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION FACILITY/SITE NAME NEAREST CROSS STREET ✓Rw lohdlcele ❑ PARTNERSHIP ❑ STATE AGENCY ADDRESS Cl CORPORANON ❑ LOCA AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY STATE ZIP CODE SITE PHONE A,WITH AREA CODE CITY NAME CA ✓Box it INDIAN EPA ID p N of TANK'S TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR 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 p WITH AREA CODE DAYS: NAME(LAST FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME QRST,FIRST) PHONE p WITH AREA CODE IL PROPERTY OWNER INFORMATION &ADDRESS - (MUST ADDRESS BECOMPLETED) CARE OF NAME ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY I ❑ 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 ✓Box tc indicate ❑ PARTNERSHIP ❑ STATE AGENCY MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL Cl COUNTY-AGENCY STATE ZIP CODE PHONE p,WITH AREA CODE CIN 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. El 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 N JURISDICTION N AGENCYIN FACILITY IDM N of TANKS Et SITE 0 0 B CURRENT LOCAL AGENCY FACILITY ID M APPRO DB NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMif&FOLIATION DATE DATE FILED LOCATION CODE CENSUS TRACT SUPERVISOR-DI ICT CODE BUSINESS PSNFILED NO � 23 � 2 FEE CODE RECEIPT N BY: CHECK PERMIT AMOUNT SURCHARGEAMOUNT 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. FORM A(3-2-88)