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STATE OF CALIFORI TX WATER RESOURCES CONTRSL BOARD a <br /> FORM 'A': _ ° <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , <br /> / <br /> ITY/SITE <br /> COMPLETE THIS FORM FOR EACH FACILhow," <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE or <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE a) <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME o <br /> ADDRESS C e NEAREST CROSS STREET ✓Nu'n otm � PAItTNMP D STATE AGENC( <br /> I`� C�JJ ❑ CUPORkTA N ❑ LOM AG ❑ ROTA(AGD+a <br /> `I 0 INDMDIAL 0 CWM-AGENCY <br /> CL <br /> ITY NA <br /> ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CITU NAME Vvy <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 D IBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID# #of TANK# <br /> 50THER RESERVATION or ❑ ATTHISSITE <br /> ❑1 GASSTATION FARM ❑ TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> NIGHTS'. NAME(LAST.FIRST) PHONE If 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 indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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 intlicate 0 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)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY 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# #of TANKS at SITE <br /> 3 / <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE#WITH AREA CODE <br /> 'Ir PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCMECK* <br /> E CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> '-')'J? YES NO `z <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MOR"ANK PERMIT FORM 'B' APPLICATION(S),UNLESS THIS K A CHANGE OF SITE INFORMATION ONLY. <br /> 1 �RIM A(3-2-88) J\ <br /> I 1 / DATA PROCESSING COPY �6/ <br />