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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ••lax/ �F FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o SITECO) FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE Fh ARK ONLY F-11 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ ' PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 1 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Box to mute ElPARTNERSHIP ElSTATE-AGENCY N -•(•� � // ❑ CORPORATION ❑ 1OCAL-AGENCY ❑ FEDERAL AGENCY 00 4,Aj ❑ INDIVOIL A, ❑ COUNTY AGENCY IP CODE SITE PHONE 4,WITH AREA CODE W ,4L CA CITY NA E STATE Z TYPE OF BUSINESS ❑ 2 DISTRIM,ITOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID u RESERVATION or p of TANK's ❑ ) GAS STATION F] :I FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYSNAME(LAST.FIRSTI PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST..FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & 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 P.WITH AREA CODE III. TANK OWNER INFORMATION & 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 P.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. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# --� APPROVED BY NAME PHONE#WITH AREA CODE 06 1 H / -- 1--_-- - - - PERMIT NUMBER PERMIT APPROVAL DATE 1 PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NOS— CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11)OR MORE TANK PERMIT FORM `B' APPLICATION(SI 1jNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.