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STATE OF CALIFORNIA.... WATER RESOURCES CONTROL..,jARD <br /> FORM 'A': ° <br /> UNDERGROUND STORAGE TANK PROGRAM �� <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> I <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT lz5 CHANGE OF INFORMATION ❑ 7 PERM �$��p� '�� f.f <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1 ti I N <br /> 00 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) h/ N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADORESS NEAREST OR OSS STREET ✓Buitai CalI 0 PWNDW 0 STATFAGDO <br /> O ( �� ❑ owm Cl TION <br /> ING0 MY AGENCY <br /> 0 FMUK AGOXY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> A76 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR F—] 4 PROCESSOR ✓Box if IN IAN EPA 10 # <br /> ❑ 1 GAS STATION ❑ B FARM Ll5 OTHER TRUSTESEYLANDS ATI or El #o1TAN <br /> 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 ✓Box to mdanne 0 PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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 /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# IT of TANKS a1 SITE <br /> [a] I I I 1 = I : <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE x WITH AREA CODE <br /> irk52 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRIC CODE BUSINESS PLAN FILED DATE FILED �. <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: \ <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. - t <br /> V� <br /> FORMA(3-2-08) �\ <br /> ` \� �... DATA PROCESSING COPY <br /> v <br />