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STATE OF CALIFORNIR WATER RESOURCES CONTRCrBOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> y/ COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> / 1 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT EYS CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CID <br /> C" <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) ? <br /> O <br /> FA /SR E CARE OF ADDRESS INFORMATION <br /> ADDR NEAREST CROSS STREET ✓Bm IO IMKaW ❑ PARRIERHN ❑ STATE-AGTNf.Y <br /> 2 D ❑❑� cC��a9POHATION ❑ LVAAGBILY ❑ FEDENLAWKY <br /> tJ I�INOMDDN ❑ owm-Araya <br /> CITY NAME STATE ZIPOE SITE PHONE N,WITH AREA CODE <br /> CA (/�J�7j <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PRGCESMR ✓Box it INDIAN EPA ID a <br /> RESERVATION or ❑ *PI TANKS <br /> ❑ i GAS STATION E21FARM ❑ 60THER TRUSTLANDS 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#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Sox to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK NER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ 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)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ It. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* - JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE <br /> Z�flI I I_q 1053 <br /> CURRENT LO Al AGENCY FACILITY ID a APPROVED 8Y NAME PHONE*WITH AREA CODE <br /> -� tJEi <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT Ar SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> e a3� 3- YES [] NO U f <br /> CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT# <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. <br /> FORM A(3 2-88) <br /> ar DATA PROCESSING COPY <br /> I <br />