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STATE OF CALIFORNIA WATER RESOURCES CONTRBOARD <br /> W: <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Lam' CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE z <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Co <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CD <br /> FACINUTY/fiPT <br /> l_ CARE OF ADDRESS INFORMATION <br /> �# ? <br /> ADDRESS NEAREST CROSS STREET ✓Box to mrai ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY EI FEDERAL AGENCY <br /> ❑ INDNmUAL ❑ GOUN1YAGRia <br /> CITY NAME \ STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> v1 CA <br /> TYPE of BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Boz if INDIAN EPA ID n #of TANK'sESE <br /> n <br /> F-11 GAS STATION F__] 3 FARM ❑ 5 OTHER TRUSTVATION LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST.FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N 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 o1 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 N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING a,STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> I I 2 z <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> UNIoTV -�3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE <br /> 2 3� YES E] NO � C� <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASWR MORE TANK PERMIT FORM B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FDRM=(a-�z�-ee> 9 DATA PROCESSING COPY <br /> 5 <br />