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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM � Ao ._ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> - C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PEE SITE <br /> ONE ITEM p INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 5Z <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) J <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS _ NEAREST CROSS STREET 2/6-WHue 0 PAATNERM 0 STATE AGDCy <br /> 0 WIPORATION 0 LOCALVANCY 0 FEDERAIAGDO <br /> ❑ INDmn.Pl 0 CUM AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> y DISTRIBUTOR TYPE OF BUSINESS: R ✓ <br /> 4 PROCESSOR Box R INDIAN EPA ID N <br /> E] I GAS STATION 3 FARM 5 OTHER RESERVATION or ❑ X o1 TANK'N <br /> TRUST LANDS AT THIS SITE <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 imIcale 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 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 indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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: 1. [::] it. ❑ III.Ej <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 N JURISDICTION k AGENCY N FACILITY ID Al B of TANKS at SITE <br /> =1 I I I 7FIZ:E I I I I EL <br /> CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE N WITH AREA CODE <br /> J S/ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED p <br /> 32-V YES NO J O7 <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT IT Y: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEACT(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S). UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM n p e-DBI <br /> L DATA PROCESa , COPY '� <br />