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P ALIFORNI WATER RESOURCES CONTROLBOARD STATE OF IG FORM `A': UNDERGROUND STORAGE TANK PROGRAM m SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,, 30 COMPLETE THIS FORM FOR EACH FACILITY/SITE cgi,Foa✓,P MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE C" ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CD L FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) �p FACIL Tf/SITE NAME CARE OF ADDRESS SNFORMATION ADDRESS NEAREST CROSS STREET ✓Bac I"indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ CAUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE k,WITH AREA CODE CA TVP OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESS ORBox if INDEAN EPA ID k #of TANK's ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHERUST LANDS RESERVATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS' NAME(LAST,FIRST) PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicaUe Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDWIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,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. ❑ IL ❑ IIL❑ 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# JURISDICTION# AGENCY# FACILITY 10# UAREA CURRENT LOCAL AGENCY FACILITY ID k APPROVE 'tY NAME PH LE ,NUMBER PERMIT APPROVAL DATE PE IT EXPIRATI DATEON CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED' /��^� YES ❑ NO ❑k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k 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(3-2-88) ( 11 DATA PROCESSING COPY 0 V —