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STATE OF CALIFOR& WATER RESOURCES CONTROL BOARD <br /> SJ`,.. -, <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ' o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> • COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY -11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O v <br /> h <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) F <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓IIAW[drale 0 PMTNfRMIP D STATEAGD0 <br /> 0 COIPOMTCN 0 LOCAL AGENCY D FEDEFk.AGB* <br /> ❑ NOMWN ❑ COATYAGENGY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑/PROCESSOR ✓BO%if INDIAN EPA ID N <br /> ❑ I GASSTATION ❑3 FARM ❑ 5 OTHER TRUSTVLANDS ATION Of ❑ #al <br /> AT THHISIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N 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 indicate D PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 011. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate PARTNERSHIP D STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE K,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. ❑ 11. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY# FACILITY ID# N of TANKS at SITE <br /> ►ALU Z 12 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE If WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT O SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE pECEIPTtl BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASOR MORE TANK PERMIT FORM 'B'APPLICATION(S),�SS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3.2-5.., <br /> DATA PROCESSING COPY <br />