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STATE OF CALIFORNI)r WATER RESOURCES CONTROMOBOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY OSEDSITE I'& <br /> ONE ITEM ❑ p INTERIM PERMIT -4❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> N <br /> FACILITY/SITE NAME /� CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Barb Wuk, ❑ PARTNBEHP ❑ STATE AGENCY <br /> [/cM1 ❑ CORPOMMN 0 LOLL AGENCY ❑ FEOEUL AGENCY <br /> 1 ❑ INDIADIIAL ❑ CGINIYAGENCY <br /> CITY NAME i STATE ZIP CODE SITE PHONE X,WITH AREA CODE <br /> CA s2cS <br /> TYPE OF BUSINESS: ❑2 DI RIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID p <br /> Ks <br /> RESERVATION or X of HIS SI <br /> ❑ 1 GAS STATION FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE M WfTH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE X WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to,rfoicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING of STREET ADDRESS ✓Bax W,ncicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X,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. 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 /> COUNTY S JURISDICTION S AGENCY N FACILITY ID R R of TANKS at SITE <br /> 101010 13 <br /> CURRENT LOCAL AGEjJCY FACILITY IDX LCODEBUSINESS <br /> PHONE X WITH AREA CODE <br /> EPERMITMBER PERMIT APPROVAL DATET EXPIRATION DATECODE CENSUS TRACT X SUPERVISOR-DISPLAN FILED DATE FILE <br /> 23 23YES NO ❑PERMIT AMOUNT SURCHARGE AMRECEIPT X BY: <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. <br /> FORM A(3-2488) <br /> DATA PROCESSING COPY <br />