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fie" O 'Ff ' I <br /> STATE OF CALIFORNtm WATER RESOURCES CONTROt BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V m Z <br /> ® �e <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ;� 10 <br /> �44rOVN�> <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PER ❑ 5 CHANGE OF INFORMATION ERMANENTLY CLOSED SITE r~ArT <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 <br /> W <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> MFACILI�/SITME CAREOFADDRESS INFORMATION <br /> �NEAREST CROSS STREET ✓ Nio# P STAIE'AGENLI' <br /> T —T 6POUTION 0 LOCAL 0 HpENL-AGOCY5 a ) �Q 1 xA ❑ INOMWAL ❑ cwtire'-AOENC! <br /> STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> STRIBUTOR d PROCESSOfl ✓Box i1 INDIAN EPA ID N _ #W TANK'# <br /> ❑yS OTHER RESERVATION or ❑ AT THIS SITE O <br /> ❑ 1 GAS STATION ❑ 3 FARM IVH TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PAYS: N.A ^ST,Ft <br /> PHONE N WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE N EA WITH ARCODE <br /> o) 01' E� - e p <br /> NIGHTS: NAME(LAST,FIRST)M� PHONE N WITH AREA CODE NIGHTS: NAME( ST ) PHONE N WITH AREA CODE <br /> / , V <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION Cl 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 ✓Sox to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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: 1. 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 8 SIGNATURE), DATE <br /> LOCAL AGENCY USE ONLrY---/ <br /> COUNTY# JURISDICTION k AGENCY# FACILITY ID# #of TANKS N SITE <br /> I C) 01 1 d o 1(0 1 ( L <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> Dr <br /> GA � <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DIST ICT CODE BUSINESS PLAN FILED DfjTE F ED <br /> olcl Z YES NO CIO <br /> '• <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> FORMA(3-2-6BJ <br /> �� DATA PROCESSING COPY �N <br />