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STATE OF CALIFORNIA WATER RESOURCESCONTROOARD {�":.o:: '? FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH fA61LITYISITE MAR NLY ❑ I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 CLOSED SITE ONE ITEM p INTERIM PERMIT E]4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I S3 I. FACILITY/SITE INFORMATION A ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS iz! nea ❑ PARTNERSHIP ❑ STATEAGENCY ON 11 LOCAL.AGRO D FEOENAL-AGDO u ❑ caNn-_- CITY NAME STATE SITEPHONE p,WIT AREACODE o CA ? y�2-/1 TYPE OF BUSINESS: 0 p DISTRIBUTOR ❑ q SSOR ✓Box if INDIAN EPA ID N I GAS STATION E]3 FARM El 5 OTHER TRUST AANDDSS or ❑ #M TANKI AT THIS SITE v EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHO N WITH AREA CODE DAYS: NAME LA FIRST ( 1 PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA DE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION A ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY C FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE Ill. TANK OWNER INFORMATION A ADDRESS—(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY 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: 1. II. ❑ 111, THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY N FACILITY ID N M of TANKS at SITE 7m KM a 0 v cl CURRENT LOCAL AqFpCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER f PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTTRA # SUPERVISOORRR--DISTRICT CODE BUSINESS PLAN FILED DATE FILED F 0 CHECK# PERMIT AMOUNT SDRC OEA NT FEE CODE YES ❑RECEIpTY. NO ❑ q— 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)