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STATE OF CALIFORNIA"' WATER RESOURCES CONTROL-LOARD 5�A'""'"'r' <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Io <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �""�""�" <br /> MARK ONLY 54 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURECD <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) cn <br /> F NAME CARE OF ADDRESS INFORMATION <br /> r <br /> ADDRESS NEAREST CROSS STREET ✓w Mme 0 LOCk-ABRP 0 STATE FEDEMLGBILY <br /> ❑ CDEFGMIIGN ❑ LGGI4AGENCl ❑ RGEMLAGRlCS <br /> '35 e r-I F}MMQ2 Alm ❑ iMMOAL ❑ CMNNAGENCr <br /> CIN NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓RESBOx it INDIAN EPA ID a >f Of TANK'# <br /> ❑ I GAS STATION 3 FARM ❑ <br /> S OTHER TRUSRYLANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box tomftate 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 IL 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#.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: L ❑ 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 M JURISDICTION# AGENCY R FACILITY ID N If of TANKS M SITE <br /> EE = = 1 1 lcd'3 3 --71 101 o 1 v <br /> CURRENT LOCAL AGENCY FACILITY ID I APP VED BY NAM PHONE#WITH AREA CODE <br /> �eoA CDC) <br /> PERMIT NUMBER PERMIT PR VAL DATE PEAMI!rEXPIRA31ON DATE <br /> LOCATION CODE CENS��UTTS TRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F ED <br /> G IX3 eo/D �$ YES [:] NO /Z SH <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTk BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM IB'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOR A(3-2-BS) <br /> �i DATA PROCESSING COPY A <br />