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STATE OF CALIFORk,i . WATER RESOURCES CON)e__ BOARD �•'> <br /> W_ A <br /> FORM #A': UNDERGROUND STORAGE TANK PROGRAM z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , to <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER LY CLOSED SITE 1'& <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Cn <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> F.or 2 so A.,4i <br /> ADDRES(Sf �j NEAREST CROSS STREET ✓fiwbi#iwle D PARTNERRNP 0 STATE AGENCY <br /> /0: J GI / 13INNDDNwIMUL D CCUNNAGDICY D FEDEPAL.AGBILY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> E /eti <br /> CA 95sa0 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box B INDIAN EPA ID a #of TANK'# <br /> ❑ 1 GAS STATION 03FARM ❑ <br /> 5 OTHER TRUSTYLANDS ATION or ❑ AT THIS 817E <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N 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 /> g!ye QS <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP DSTATE-AGENCY <br /> 0 CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> I NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP D FEDERAL-AGENCY 0 CORPORATION D LOCAL-AGENCY 11CFEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> I <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. II: ❑ 111.❑ <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# a of TANKS at SITE <br /> I <br /> CURRENT LOCAL AGENCY FACIL ID If APPROVED BY NAME PHONE If WITH AREA CODE <br /> Salic- <br /> 14 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> [CHI <br /> CATION CODE CENSUS TRACT N SUPERVISORAISTflICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23, <br /> 2--k <br /> a YES NO G <br /> # PERMIT AMOUNT SURCHARGE AMOU14 <br /> NT 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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br /> T FORM a(c-2S-Be) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />