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STATE OF CALIFORROIA WATER RESOURCES CONTOL BOARD FORM NA': UNDERGROUND STORAGE TANK PROGRAM a4n 4 I;W0 SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' °,!� COMPLETE THIS FORM FOR EACH FACILITY/SITE HMARKNMLY ❑ 1 NEW PIRMIT ❑ 3 RENEWAL PERMIT ❑�HANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 6 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓EmoxNma ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDDA4 AGENCY Cl INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE 21P CODE SITE PHONE N.WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DIST UiOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p N of TANN1 ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS oT ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WIT H AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to lndicale ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY 71 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AgEA CODF. 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ' MAILING or STREET ADDRESS ✓Box to ladicale ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ 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: 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE 121 CURRENT LOCAL AGENCY FACILITY ID Al APPROVED BY NAME PHONE N WITH AREA CODE i6 s PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FI ED YES ❑ NO y CHECKN PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT At BY: 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(3-2nB) DATA PROCESSING COPY