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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD f 7 FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� COMPLETE THIS FORM FOR EAC AGILITY/SITE �"(�FORN�P MARK ONLY ❑ f NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE O ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Cj I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE AGENCY wok ❑ CORPORATION 11El ❑ FEDERAL-AGENCY ( ❑ INDIVIDUAL LOCAL -AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR F-14 PROCESSOR ✓Box if INDIAN EPA ID # ❑ ❑ ❑ TRUSE'ERESET LANDS ATION or ❑ #of HIS S 1 GAS STATION 3 FARM 5 OTHER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE 11. 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#,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 It,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. ❑ 11. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE MII1-3 1 CURRE LOCAL AGENCY FACILITY 1 # APPROVED BY NAME PHONE#WITH AREA CODE 3 PERMIT N MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED WC ��r z_1 YES NO 3 "T CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: a I THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) 2� �_6\\ 46 DATA PROCESSING COPY I//]