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STATE OF CALIFORNR WATER RESOURCES CONTROL BOARD FORM 'A': " UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY C OSED SITE F- ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE J� __j Y I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CO p FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓60�Mfol.e C PARTNERSHIP C STATE AGENCY C CORPORATION C LOCA#GENCY C FEDERALAGENCY C INDIVIDUQ C COUNTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS: F-12 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN RESEEPA ID N N of TANK's E] 1 GAS STATION [—] 3 FARM ❑ 5 OTHER TRUSRTYLANDS ATION or ❑ AT THIS SITE - EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH 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 indicate C PARTNERSHIP C STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY C FEDERAL-AGENCY ❑ INDIVIDUAL C COUNTYAGENCY CITY NAME STATE I ZIP CODE PHONE N,WITH AREA CODE ill. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bo.to,fo,cwe C PARTNERSHIP C STATE-AGENCY C CORPORATION C LOCAL-AGENCY C FEDERALAGENCY C INDIVIDUAL C COUNTYAGENCY 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. ❑ it. ❑ 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY K JURISDICTION M AGENCY M FACILITY ID K If of TANKS at SITE 3y I I I 6 I CURRENT LOCAL AGENCY ILITY ID M ` APPROVED BY NAME PHONE F WITH AREA CODE i 5 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LE YES NO WVw CHECK♦ PE AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N Y: THIS FORM MUST BE ACCOMPANIED BY AT LEAST OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNI ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. _- FORM A(3-2-88) DATA PROCESSING COPY • /