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STATE OF CALIFORNIA WATER RESOURCES CONTROL OARD <br /> ei SE V. it"..h\ <br /> W: o <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM M1�m <br /> SITE FACILITY/SITE, INFORMATION and/or P RMIT APPLICATION 1 <br /> (J dCOMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT tl 5 CHANGE OF INFORMATION ❑ 7 NTLY CLOSED SITE rV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE � � . <br /> I. FACILITY/SITE INFORMATION & AD RESS — (MUST BE COMPLETED) �p <br /> FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> ADDRESS !� NEAREST CROSS STREET ✓GOX IOORATIIO ❑ PAATNEAGEN ❑ FEDERAAGEN <br /> ,) J( ❑ <br /> CORPORATION ❑ LOCAL ❑ FEDERAL AGENCY <br /> V ❑ <br /> INDIVIDUAL ❑ COUNttAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> I CA <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ d PROCESSOR I ✓Box if INDIAN EPA ID # <br /> ❑ <br /> ❑ 1 GAS STATION E:] RESERVATION or If of TANI <br /> 3 FARM ❑ 5 OTHER TRUST LANDS AT 7XIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYG'. NAME((LAST,FIRST) PHONE#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 INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME y CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Z ❑ CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 11 COUNTY-AGENCY <br /> CITU NAME STATE ZIP CO PHONE# WITH AREA COO <br /> C -o C1 v, <br /> III. TANK OWNER INFORMATION & ADDRESS — ( UST BE COMPLETED) <br /> NAME �(y�� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <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: I. ❑ it. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY P JURISDICTION R AGENCY R FACILITY ID N R of TANKS at SITE <br /> o � 3 � 6o 0 <br /> CURRENT LORAL AGE FACILITY ID# PROVED BY NAME PHONE N WITH AREA CODE <br /> C) <br /> PERMIT NUMBER RMIT APPROVAL DATE PERMIT EXPIRATION <br /> LOCATIOONC DE CENSUS TRACT k SUPERVISOR-DISTRICT DE BUSINESS PLAN FILED DATE FILED <br /> / Z 2 'L YES ❑ NO zf— Q <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT I FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE K PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS ANGE OF SITE INFORMATION ONLY. <br /> \ FORM A(3-2-88) \.l <br /> 0 • ATA PROCESSING COPY • <br />