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STATE OF CALIFORNII* WATER RESOURCES CONTRdeBOARD5f^'""" <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ° o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° +o <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE "li,c. I <br /> MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE - <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) co <br /> FACILI ITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS �� _ NEAREST CROSS STREET I/BW to irdial ❑ LOCALAEN ❑ FEDM-AGEN <br /> Cg�JJj ❑ OMTION ❑ LGMIAGCY ❑ STATE A-AGEN6Y <br /> INGINWAL ❑ COUNTYAGENCY <br /> CITY NAME STATE Z}H CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE of BUSINESS:v ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA 10 a #of TANKS <br /> j ❑ 1 GAS STATION FARM ❑ 5 OTHER TRUSTYLANDS ATION or 1:1AT 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 a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#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 Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY O FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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: 1. ❑ IL ❑ 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 S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It AGENCY# FACILITY ID# #o1 TANKS at SITE <br /> CURRENT L CAL AO�;�;F ITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER �`/J/ PERMIT APPROVAL DATE #CODEBUSINESS <br /> T EXPIRATION DATE <br /> I <br /> LOCATION CODE CENSUS TRACT# SUPERVIS R-DISTRICPLAN FILED DATE FILED <br /> �!� YES ❑ NOCHECK# PERMIT AMOUNTT SURCHARGE AMOUNT RECEIPT# 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 /> 1 FORM A(3-2-88) - <br /> `Y\`\`11l �/ DATA PROCESSING COPY ��I <br />