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AN, <br /> yt to <br /> NATE OF CALIFORNIh.- WATER RESOURCESCONTFi0ae0ARD <br /> ORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATI <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE ( 0 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ T PERMANENTLYCLOSEDS: <br /> :j <br /> ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE - Q z <br /> Im <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITYIS�1T,E NAME _TCARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET as wwals 0 PARTNERSHIP 0 STATE AGENCY N <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 LOCAL-AGENFEDERALAGENCY <br /> pLv.J 34.3 0 INDMWAL 0 COUNTY AGENCY i(V7ji]LI <br /> CITY NAME U STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> (4K I CA <br /> TYPE OF BUSINESS: F-12 DI1J10R ❑4 PROCESSOR ✓Box 0INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> ❑ 1 GASSTATION E]3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS NAME(LAST,FIRST) PHONE IT WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It 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 intlicate 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#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS */Box tointlicate ❑ PARTNERSHIP 1:1 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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 /> COUNTY# JURISDICTION At AGENCY# FACILITY ID# #of TANKS at SITE <br /> X57 = = CSU 31 I <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ED <br /> YES NO ❑ 0 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UIJLESS THIS IS A CHANGE OF SITE INFORMATION 0 . <br /> FORM A(3-2-88)r <br /> DATA PROCESSING COPY A� <br />