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-- <br /> STATE OF CALIFORNIA`' WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATFOh�� <br /> v COMPLETE THIS FORM FOR EACH F LITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P ENTLY CL DSITE 0 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ( C I ) <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) \ <br /> FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> ADDRESS I/J�� V '/ NEAREST CROSS STREET ✓9mnn6me Cl PA9tNE9HP Cl STATE-AGRILY <br /> "� '� V /� (/� ❑ COIfO om ❑ Lom AGBILY Cl MERk*W0 <br /> L ) !_ ❑ ',vw' Cl WIMIYAGFNI:f <br /> CITY NAME ! !" STATE ZIP CODE y, 7 SITE PHONE a,WITH AREA CODE <br /> ` CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 _/BRE ox ii INDIAN EPA ID 4 t of TANK's <br /> ❑ I GAS STATION ❑ 7 FARM ER TRUST LANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(UST,FIRST) PHONE X WITH AREA CODE DAYS NAME(UST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(UST.FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a 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.mcate C PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> 0 0 Cl INOMDUAL Cl COUNTY-AGENCY <br /> CITY NAME -T STATE ZIP OOOE PHONE a.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 C PARTNERSHIP C STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY C FEDERAL-AGENCY <br /> ❑ INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(T)BOXTNDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND SILUNG: it.ir III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION M AGENCY R FACILITY IDR B of TANKS at SITE <br /> = = D 1 13]_ <br /> CURRENT LOCAL AGENCY FACILQY ID a APPROVED BY NAME PHONE 4 WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION PATE ^� <br /> LOCATION CODE CENSUS TRACT 4 SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> YES NO [j <br /> CHECK a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a <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(3-2-SR) <br /> Yv'w DATA PROCESSING COPY <br />