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STATE OF CALIFORNIX WATER RESOURCES CONTRO-C BOARD '`� <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM <br /> o <br /> S <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 7 ' r <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•o�`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT u 5 CHANGE OF INFORMATION 7 P LY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME ^^ CARE OF ADDRESS INFORMATION <br /> '1 <br /> ADDRESSyy -) NEAREST CROSS STREET ✓gavbiMsb D PARTNERSHIP Ill SATEAGENCY <br /> 3 35 0 ` D COWORATIGN D LOCA-AGENCY 11 FEDI <br /> ❑ INorio Al D COIINIY AGENCI <br /> CITY NAME / Or STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> /LCL^,dir, CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID a <br /> ❑ I GAS STATION �ApM ❑ S OTHER RESERVATION or ❑ - ATIf THIS SITE TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(HAST,FIRST) PHONE 4 WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> fi w rlo s. ' o ti — <br /> NIGHTS. NAME(LAST.FIRST) PHO N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE IF WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME S 1 CARE OF ADDRESS INFORMATION <br /> MAILING or STREET DDRESS /L ✓Sox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> Cl INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME S /�- CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STRI ADDRESS ✓Box to indicate D PARTNERSHIP D STATE AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE 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: 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'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY IDN k o/TANKS M SITE <br /> 3 ` <br /> 0d44 I � I '? I )J I nl DSO <br /> CURRENT LOCAL AGENCY FACILITY ION APPROVED BY NAME PHONE N WITH AREA CODE <br /> —_T <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN <br /> YES NO NG ❑ DATE FILED, _ <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• Y: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> S <br />