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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> 1 '•tf <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM V <br /> m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 10 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ ERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> r <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Ba N native 0 PARTNERSHIP 0 STATE AGENCY <br /> -58 <br /> II 0 CORPOUTION ❑ LOCK.-AGENCY 0 FEIEAAL AGENCY <br /> �,(f ❑ IN>IvlGuu ❑ COUNTY-AGDra <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 D19MIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID k <br /> RESERVATION or If of TANK's <br /> ❑ 1 GASSTATION ❑ 3 FARM ❑5 OTHER TRUSTLANDS ❑ I AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#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 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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 0 PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE p,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. 1-1 11. ❑ 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 6 JURISDICTION a AGENCY N FACILITY ID N a of TANKS at SITE <br /> Em I I I / 151 1 1 10 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENBUSTRACT* SUPERVISOR-DISTRICT CODE BUSINES,PSNFILED NO ❑ DATEFILED / <br /> J 3 <br /> CHECK K PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNI FSS THIS IS A CHANGE OF SITE INFORMATION ONL'(.I C( <br /> FORM A(3-2-88) ^n\UC O <br /> ,-"-) lO-C{-�\ D DATA PROCESSING COPY <br />