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STATE OF CALIFORA WATER RESOURCES CONTROSOARD . TM1F 0 _ A FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° ,; to COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE I" ONE ITEM 2 INTERIM PERMIT E] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESSNEAREST CROSS STREET ✓Box loird¢ale D PARTNERSHIP D STATE AGENCY L Cl CORPORATION D LOCAL AGENCY D FEDERAL AGENCY ❑ INDMDUAL D COUNTY AGENCY CIN NAME STATE ZIP CODE SITE PHONE ft.WITH AREA CODE CA TYPE OF BUSINESS: 0 2 DISTRIBUTOR 4 PROCESSOR ✓Bax if INDIAN EPA ID It Rol TANICs 1 GAS STATION 3 FARM r?r5 OTHEfl TRUST LANDS VATION or ❑ AFT SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D 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 ✓Box to indicate D PARTNERSHIP D STATEAGENCY D CORPORATION D LOCALAGENCYD FEDERALAGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CNECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY41 JURISDICTION R AGENCY R FACILITY ID R a of TANKS at SITE ,3 q I I I I jio � I I I I I L CURTRENT LOCAL AGENCY FACILITY ID a APR ED BY NAME I PHONE a WITH AREA CODE I 1 ^• PERMIT NUMBER PERMIT APPROVAL DATE P MIT E%PIR ION DATE OQ LOCATION COD CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ll 2 a YES NO CHECKII PERMIT AMOUNT SURCHA✓RGE AMOUNT FEE CODE RECEIPTM Y: 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. FORMA(3-2-68) DATA PROCESSING COPY •