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.rhe <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> WP.• �1 <br /> FORM `A': V_ ` <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> m <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE 1" e09—P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA Y CLOSED SITE Z <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION W <br /> ADDRESS all'i <br /> NEAREST CROSS STREET ✓Box to nCicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> O[� - j5eG� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Q J ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME ]] � STATE Z CODE SITE PHONE#,WITH AREA CODE <br /> CA D <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR bD�4 P ESSOR ✓Box i1 INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS NAME(LAST,FIRST) PHONE it WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> NIGHTS' NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATIO 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 ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUK BE COMPLETED) <br /> NAME NlARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS . indicate 1:1 PARTNERSHIP ❑ STATE-AGENCY <br /> RF ORATION 11LOCAL-AGENCY ElFEDERAL-AGENCY <br /> IDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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 NOTIFICATM AND BILLING: I. ❑ 11. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF M NOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) ATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ® ❑ sI � a0__F0 <br /> _l <br /> [CURRENT OC L AGF�{CYq�ITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMMBB/ER I�J PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 7 <br /> LOCATION CODE CENSUS TRACE# SUPERVIS STT CODE BUSINESS PLAN FILED DATE FILE <br /> 3 , 6(l YES ❑ NO 7 <br /> L <br /> K# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <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(3-2-88) <br /> ��, DATA PROCESSING COPY <br />