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STATE OF CALIFORNIK' WATER RESOURCES CONTROL-60ARD <br /> 9EFl <br /> xM1\ <br /> f <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 1110, <br /> "Fo ate`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Ej?7PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACIUN SITENAME CARE OF ADDRESS INFORMATION <br /> I'Avl <br /> ADDRESS �� N REST CROSS STREET ✓8wbNose ❑ PARIMMIP ❑ $ATE AGENCY <br /> �-y/�. ,(\�(i+�/ ❑ W WORITION ❑ LOGE AGENCY ElFEDERAL-AGENCY <br /> r ❑ INDMOU1 ❑ CoiATY-AGENC/ <br /> CIN NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA a <br /> TYPE OF BUSINESS: ❑ 2 DI RIBLJTOR ❑ A PROCESSOR ✓Box if INDIAN EPA ID N <br /> ❑ 1 OAS STATION FARM 5 OTHER RESERVATION or }� �/(,. N of TANK's <br /> ❑ TRUST LANDS ❑ / k" � AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> ENIGHTT. <br /> FIRST) PHONE X WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> u 9 FIRSTT)) , If PHONE N WI H AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME i CARE OF ADDRESS INFORMATION <br /> S � <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY O 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 SIRE 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 ADORE"SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 11. ❑ 111. ❑ <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 N JURISDICTION N AGENCY N FACILITY 10 N N of TANKS M SITE <br /> C� <br /> CURRENT L CAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> MR&L)l <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTN SUPERVISORAISTRICT CODE BUSINESS PLAN FILED DATE FILED C <br /> 3> �{�� YES NO a <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N f 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 <br /> FORMA(32W)V <br />