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STATE OF CALIFORNM WATER RESOURCES CONTROL BOARD <br /> FORM 'A': i <br /> UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - IC <br /> ="� �o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE c""�°��� <br /> MARK ONLY F-1 I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 <br /> n <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) OD <br /> FACILITY SITE NAMEI CARE OF ADDRESS INFORMATION <br /> n <br /> J i <br /> ADDRESS NEAREST CROSS STREET ✓Boob Mvste ❑ PAATNEABHIP ❑ SfA1EAGENCY <br /> I31 ❑ WRPO ATION 0 LDDALAMC( 0 FEOEAAL.AOM <br /> ❑ IxorviouAL 0 wuxtt-ABB+CY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> j CA <br /> TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR RESERVATION or✓Box if INDIAN EPA ID a M of TANKS <br /> ❑ <br /> I GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS F-1 <br /> ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE 0 WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#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 D PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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 Cl PARTNERSHIP Cl STATE-AGENCY <br /> D CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. ❑ it. ❑ III.❑ <br /> TTI <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) GATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a AGENCY R FACILITY ID a a of TANKS at ITE <br /> p <br /> CURRENTL CAL AGENCY FACILITY IDK APPROV OBY NAME PHONE a WITH AREA CODE <br /> ' z± a <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRAC a SUPERVISOR-018 CODE BUSINESS PUN FILED DAM FILED <br /> 'p7' 3.� - YES ❑ NO ❑ y 40NLY. <br /> CHECK• PERMR AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT0 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 INF <br /> FORM A(3-2-88) <br /> lDATA PROCESSING COPY <br /> i \v�J <br />