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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD r <br /> A <br /> A <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAMio <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m : <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE F� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E:] 7 PERMANENTLY CLOSED SITE �1 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE NO <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W <br /> W <br /> FACILITY ITE NAME _ CARE OF ADDRESS INFORMATION W <br /> .�. I..a <br /> ADDRESS NEAREST CROSS STREET ✓BmbYkiwle ❑ PMTNHt%flP ❑ SLATE AGENCY <br /> ❑ CNDMD A10N ❑ l4CAl-AGENLY ❑ STATEA-AGENLY <br /> 11 <br /> CITY NAME STATE ZIP ODE SITE PHONE N.WITH AREA CODE <br /> CA 45 <br /> TYPE OF BUSINESS. ❑ 2 016NIBUTOR ❑4 PROCESSOR ✓Box d INDIAN EPA ID N M of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5OTHER TRUSTTATION LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(I-AST,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 ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ 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)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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 /> CJOU�NT�Y/R � JURISDICTION N AGENCY R FACILITY ID N /�, N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> El <br /> CENSUSTRACT�L, SUPERVISOR ISTRICT CODE BUSINESS PLAN FILED DATE FIL <br /> 3YES NOPERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPTN T: <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. C <br /> A -Z-�1 <br /> f /\) <br /> �-+ DATA PROCESSING COPY .may <br />