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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> PI a.P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 1-1 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE 1 <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W <br /> u� I <br /> ADDRIrSS NEAREST CROSS STREET ✓Bmb Mane ❑ PIAINDEHIP ❑ STATE-AGBlC! r <br /> 0 WIBUNATION 0 LOCk AGDO 0 FEDEW AGDO <br /> 0 IWMWAL 0 000n AGEN9 <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> L CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR F-1 CPROCESSOR ✓Box if INDIAN EPA ID N <br /> ❑ ❑ ❑ RESERVATION or ❑ #of TANK'# <br /> 1 GAS STATION 3FARM SOTHER TRUST LANDS ATTHISSITE <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 /> NIGHTS: NAME(LAST,FIRST) PHONE#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 I/Box to indicate Cl PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ar STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ II. ❑ 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 R JURISDICTION N AGENCY R ID R If of TANKS at SITE <br /> m = = I qu > <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE If WITH AREA CODE <br /> PEITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> I <br /> LOCATION CO E CENSUS TRACT SUPERVISOR-DISTRICT ODE BUSINESS PLAN FILED DATE FILE <br /> 7 T �� YES NO / <br /> CHECK# PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT L FAST(1)OR MORE TANK PERMIT FORM'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMA40 / <br /> FORM A(3-2-88) >_ <br /> DATA PROCESSING COPY `� <br />