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FrT _ <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD r� " <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `^�i.oRa`^ <br /> 10 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDEOPERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> t. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF AD/DRESS INFORMATION <br /> / )Uq cu <br /> ADDRESS NEAREST CROSS STREET ✓BmbiGrak ❑ PAPMFASHIP ❑ STpTEpGENLY <br /> S S. ,) ❑ CGiPDNRTIDN ❑ IDCALAGENCY ❑ FEDERAL AGDO <br /> ❑ INDMIDUk ❑ WUI/IYAGENU <br /> CITY NAME STATE ZIP CODE SITE PHONE C WITH AREA CODE <br /> S k CA Q5aO( <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box A INDIAN EPA ID a #W TANKS <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST Gr ❑ 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#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If 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 intlicate ❑ PARTNERSHIP 11 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE$1,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 intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. ❑ If. ❑ 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# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATEFILED <br /> / 13 •STD 32-5— YES ❑ NO ❑ 7 /L qr <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY e-0- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST If 1 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNI FSS THIS IS A CHANGE OF SITE INFORMATION ONLY. 0\ <br /> FORM A(3-2-88) <br /> ,. - DATA PROCESSING COPY ""� <br />