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STATE OF CALIFORIII WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM _ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION / <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE --- <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑'5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE r1 <br /> ONE ITEM ❑ 2 INTERIM PERMIT 1:14 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> a <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> n N <br /> FACILITY/SITE NAME •V/' — CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓CORPORipk 0 PARTNEFsHw AGENCY <br /> O STATE <br /> 0 CORPORATION N 0 COUNTMkHNY ❑ FFOEML-xGFNCY <br /> Cl IxGlmouxL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 P ESSOR ✓Bon it INDIAN EPA 10 0 <br /> RESERVATION or ❑ M of TANK't — <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 ER TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Be.to indicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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 STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP Cl STATE AGENCY <br /> ❑ CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTYAGENCY <br /> CIN NAME STATE ZIP CODE PHONE x.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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> m v <br /> CURRENT LOCAL AGENCY FACILITY ID N11'' '' APPROVED BY NAME PHONE M WITH AREA CODE <br /> T/ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHECK PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 /> FORM A(3-2-118) <br /> DATA PROCESSING COPY `� <br />