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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM IA': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> I ° <br /> SATE ztc <br /> x FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 P EN YCLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE l Cr. <br /> Lr <br /> A <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) -A <br /> FACILITY/SITE NAME ,( j� CARE OF ADDRESS INFORMATION <br /> ADDRESS (/,_yyL9��• C,J //� NEAREST CROSS STREET ✓Bo.wm ❑ PMTNER911P ❑ STATE MEND <br /> /6V b W '�/Y H(i / :✓'J� NpP1WTYD Cl FEML�GEGYO INDIVIDUAL Cl 6NMEN <br /> CITY NAME STATE 21P CODE SITE PHONE N,WITH AREA CODE <br /> CA s 7 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROOSSOR ✓Box,t INDIAN EPA ID N N o(TANK'sESE <br /> �) <br /> ❑ 1 GAS STATION E]3 FARM ❑ 5 OTHER TRUSTY <br /> ATION LANDS or ❑ AT THIS SITE V <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N 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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE Al,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 ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERALAGENCY <br /> Cl INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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: 1. ❑ 11. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY X JURISDICTION B AGENCY X FACILITY ID# B of TANKS at SITE <br /> 5� <br /> CURRENT LOCAL AGENCY FACILITY to N APPROVED BY NAME PHONE M WITH AREA CODE <br /> 2 e / � <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TT¢RACT0 SUPERVISOR-DISTRICT ODE BUSINESS PLAN FILED DATE FILED <br /> ICU..))){"') "! EI 0 � !i YES NO ❑ _ / D <br /> \ CHECK# PERWTAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> 6 <br /> xQ THIS FORM MUST BE ACCOMPANIED BY AT I­OT(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONISt UNLESS THIS IS A CHANGE OF SITE INFORMATION ONyT-- <br /> -.. FORM A(3-2-88) J` <br /> DATA PROCESSING COPY n.F <br />