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STATE OF CALIFORNIA- WATER RESOURCES CONTROL BOARD `'"' <br /> FORM `A': a��. . •� <br /> UNDERGROUND STORAGE TANK PROGRAM � �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION P X <br /> to <br /> 1 COMPLETE THIS FORM FOR EACH FACILITY/SITE "'�""' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT �5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE pp <br /> ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE S3 <br /> r <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) r+ <br /> FACILITY/SITE AME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓BaxbldGN 1-1 PARTNERSHIP 0 STATEdADENCY <br /> p �' 0 0OFFOM71ON 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> (, 0 INDIVIDUAL 11 WUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 019 BUTOR ❑ 4 PROCESSOfl ✓BO%d INDIAN EPA ID# <br /> M o1 TAMC <br /> EAION <br /> ❑ 1 GAS STATION ❑3 FARM E] 5 OTHER TRUSTT LANDS a E] AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE if WITH AREA CODE <br /> NIGHTSNAME(LAST.FIRST) PHONE if WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#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 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE HONE 10,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ 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. ❑ 11. ❑ Ill.❑ <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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> / a <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIOnN CODE CENSUS <br /> TRACT#. SUP ERYI -DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> v 3 tel;`//) 3 YES NO ❑ /� (� <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:, <br /> THIS FORM MUST BE ACCOIAPANIED BY AT LEAST 111 OR MORE TANK PERMIT FORM `B' APPLICATION(S),UNLESS THIS IS A CHARGE OF SITE INFORMATION ONLY. O <br /> FORM A(3-2-88) TV\ <br /> Y t l 1/,-� ✓` I — DATA PROCESSING COPY <br />