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STATE OF CA41FOR& WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM a � o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONm <br /> COMPLETE THIS FORM FOR EACH FA ITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMA LY CLOSED SITE E <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ #AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> GA 0 1 < <br /> ADDRESS NEARIVF C PEET 13 STATEAGBwYY/` 11 WNPOIATION RftAQENC1 <br /> ❑ FEOERALAGENGY <br /> ❑ INDMW.LL ❑ COON7TAGENCf <br /> CITY NAME STATE 21P CODE / SITE PHONE N,WITH AREA CODE <br /> CA J 4 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ PROCESSOR ✓Box i11NDIAN EPA ID N #of TANMF <br /> I GAS STATION ❑3 FARM ❑ 5 OTHEA TRUSRESETYLANDS ATION m ❑ AT TRIS SITE L/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AflEA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toindi"ie ❑ 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 or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <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)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(POINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY B FACILITY ID N #of TANKS at SITE <br /> ® = = IQ 10 <br /> CURRENT LOCAL AGENCY FACILITY 101/Iy APPROVED BY NAME PHONE N WITH AREA CODE <br /> n <br /> PERMIT NUMBER PERM APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION COD CENSUS TRACT N (� SUPERVIS -D�I7STRICT ODE BUSINESS PLAN FILED DATE FILE <br /> 0 .7/ �/ a [/ YES 0 NO � � � �d <br /> CHECK# PERMIT AMOUNT SUACHARbEAMOU T FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT (1(OR MORE TANK PERMIT FORM 'B'APPLICATIONONLESS THIS IS A CHANGE OF SITE INFOR ON <br /> FORM A(3-2-88) <br /> —`O DATA PROCESSING COPY <br />