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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM F-12 INTERIM PERMIT ❑ NTLY CLOSED SITE N <br /> ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE CF) <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) uY <br /> N <br /> FACILITY/SITE NAME <br /> 1 �J -, ( CARE OF ADDRESS INFORMATION <br /> Q <br /> ADDRESS <br /> NEAREST CROSS STREET ✓go,p � p,,gTNNy1P ❑ SiaiEAGENLY <br /> F -T(�i/V 1- ElCoR l o LIXA AGEN ElFE11F61L.ASENLY <br /> CITY NAME ❑ INfxVIL111AL ❑ CWNHAUND <br /> STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> TYPE OF BUSINESS: Elt DISTRIBUTOR ROCESSOR J ox it INDIAN EPA CA <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER RESERVATION or ❑ N of TANK'N <br /> TRUST LANDS 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,FRRSTI <br /> PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Intlicale ❑ PARTNERSHIP <br /> ❑ CORPORATION ❑ LOCAL AGENCY STATE-AGENCY <br /> CIN NAME ❑ INDIVIDUAL I] COUNTY-AGENCY FEDERAL AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARL OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS J Box to in0icale El PARTNERSHIP <br /> ❑ CORPORATION ElLOCAL-AGENCY Cl <br /> Cl STATE-AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY AGENCY FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE B,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: I. ❑ II. ❑ ill. ❑ <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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTIONN AGENCYp FACICILLIITY IDDNNNIf <br /> 3 � � I�KS of SITE <br /> CURRENT LOCAL AOENCY FACILITY IDN APPROVED BY NAME <br /> STE� PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT• SUPERVISOR-DISTRICT ODE BUSINESS PLAN FILED <br /> UST DATE FILE <br /> 6CJ <br /> CHECK YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> RECEIPTN BY: <br /> !N <br /> IS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLF�A THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOR A(3-2-SS) <br /> C'O <br /> DATA PROCESSING COPY �"" ' <br />