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STATE OF CALIFORNIA WATER RESOURCESCONTROL�OARD '•tx'""` 'F <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> COMPLETE THIS FORM FOR EAC7 FACILITY/SITE <br /> MARK ONLY ❑ 1 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 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITYBITE NAME CARE OF ADDRESS INFORMATION <br /> LlI. <br /> ADDRESS NEAREST CROSS STREET ✓Betio 6 D PARMETBHIP D <br /> 801 D wro st STATE AGNY <br /> o � o fmo �Wa <br /> IND kA� <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> -foe "FON CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 1 PROCESSOR ✓Box II INDIAN EPA ID p <br /> E] 1 GAS STATION E] 3 FARM ❑ 5 OTHER TRUSTRESEVLAND$ATION ur E] N M TANK'S <br /> 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 /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toinoic to D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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 mioete D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL ❑ 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. ❑ 11. ❑ 111. ❑ <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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS of SITE " <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE Y WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PLAN PLED DATE FILE <br /> /Z / YES ❑ NO ❑ / g <br /> CHECK# PEO AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: C, 4 <br /> 17 <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. O` <br /> \FORM A(3-2-88) 1 <br />