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,aEM i.. <br /> STATE OF CALIFORNI11 WATER RESOURCES CONTROROARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ="' r A, <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C/ <br /> COMPLETE THIS FORM FOR EACH FCILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PE TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 411 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME ,,�� CARE OF ADDRESS INFORMATION <br /> 7CA/�5 T T Y pn�60 <br /> NEAREST GROSS STREET ✓Bm IDix.r 0 PARTNEFNIIP D STATE AGENCY <br /> ADDRESS �1 / 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY <br /> •/,y // / /,n.n�,e ❑ INOMWAL 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP COD / SITE PHONE N,WITH AREA CODE <br /> CA J��b <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDI EPA IDN 0 of TAMPS <br /> RESERVATION or1:1AT THIS SITE <br /> ❑ I GAS STATION F—] 3 FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME LA IRST) PHONE N WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to iotlicate D PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERALAGENCY <br /> Cl INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. ❑ If. ❑ 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 /> COUNTYY# JURISDICTION M AGENCY Nn FA/CI/LITY ID N M of TANKS at SITE <br /> FT: <br /> CURRENT LOCALO NCY F CILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER M O 2 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED p <br /> ,L Z / � YES NO Ff��E <br /> CHECKN PERMIT AMOUNTSURCHARGE AMOUNT FEE CODE RECEIPTN BY: ev�� <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 j_', <br /> S <br />