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STATE OF CALIFORNO WATER RESOURCES CONTROBOARD <br /> .: s <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM ENTI V OSED SITE N <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1,577 � <br /> III Lrl <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) rn <br /> a <br /> FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> ADDRESS a NEAREST CROSS S1�1 <br /> re 0 PARTNERSHIP 0 87A7EAGENCY ' <br /> ION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ COUNT AGENCY <br /> CITY NAME STATE ITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS or ❑ #of <br /> AT THHISIS SITE ig <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE ft WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to md,i .le Cl PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERALAGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box lointl,c.[. ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE q,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID If #of TANKS at SITE <br /> a 3 ; 3 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> AJAI-47 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Z�,�O <6 YES NO /S <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM_MUST BE ACCOMPANIED BY AT LEAST f1 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3 • <br /> DATA PROCESSING COPY \v/j <br /> U� �v <br />