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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> zAx` ?b <br /> F <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK,ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ]7 PERMANENTLY CLOSED SITE 7y <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE # <br /> .7 <br /> I. FACILITY/SITE INFORMATIONA ADDRESS- (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> r <br /> ADDRESS NEARE`GT CPO SS STREET ✓Pq[NMOY El PARTNERSHIP El STATE AGENCY <br /> SA- , CICu PglAT10N 11LOCAL AGENLY 13 FEDERAL AGENCY <br /> N{ ❑ INWAO ❑ COUNTYAGENCY <br /> CIN NAME STATE ZIP CODESITE PION p,WITH AREA CODE <br /> CA 93 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P CESSOR ✓Boz if INDIAN EPA ID Al <br /> RESERVATION or #of TANK'L <br /> ED GAS STATION ❑3 FARM OTHER 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 N WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION ! DDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box tointllcate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY C FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR kTH LEGAL NOTIFICATION AND BILLING: L ❑ II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,A TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> D0 1 A 44 to 1-5 aoao <br /> CURRENT LOCAL AGENCY FAC91 1 D# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER (,g PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE //`�I <br /> C� CHEC N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE YES ❑RECEIPTING ❑ BY: lh. <br /> ON- <br /> `\ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY..l I <br /> FORM A(3-2-88) ppp` x <br /> �._. DATA PROCESSING COPY Al \ <br />