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os� <br /> STATE OF CALIFORN09 WATER RESOURCES CONTROLD <br /> r . A <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT F—] 3 RENEWAL PERMIT MeCHANGE OF INFORMATION ❑ 7 P RMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE IFN <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) 00 <br /> co <br /> FA ITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> e h <br /> ADDRESS NEAREST CROSS STREET I/Bra to indirate 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ CO RATION 0 LOCALAGENCY 0 FEDERALAGRI <br /> NIDUAL 0 COUND'AGENCY <br /> CITY NAME C � STATE ZIP CODE $ITE ON p, ITH A�ArOf�EI4 <br /> TYPE OF BUSINESS: ❑ 2 DIST TOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # C 3 `.J{ <br /> RESERVATION ar #of TANK's <br /> ❑ 1 GAS STATION AqM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: 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 CARE OF ADDRESS INFORMATION <br /> s al_)� <br /> MAILING orSTREET ADDRESS %/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <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. lal 11. ❑ 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# F _I #of TANKS at SITE <br /> Ml I I L I A / I &� <br /> CURRENT LOCAL AGENCY FACILITY ID Ar ^ APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER An PERMIT EXPIRATION DATE <br /> LOCAT N DE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> A 3 x a YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> Bit- <br /> THISFORMMUSTBE 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 />