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STATE OF CALIFORNIA WATER RESOURCES CONTRONOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM1 l <br /> SITE /; ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO5P4197 �'A' <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 6( cn <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) A <br /> OD <br /> FACILITY/SITE NAME I ' CARE OF AD RES INFORMATION <br /> '/C SC 4 <br /> ADDRESS INEAREST CROSS STREET ✓ED.b Vdicre 0 PARTNEINFIP 0 STATE AGEND <br /> yc ❑ CORPORATION ❑ LOCAL AGENCY 0 FEDERAL AGENCY <br /> L_ 0 INDIVIDUAL ❑ COUNWAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> N CA , <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOfl ✓Bo%if INDIAN EPA ID R <br /> RESERVATIONar M or TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT TNIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION D LOCALAGENCY0 FEDERALAGENCY <br /> Cl INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,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 indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL AGENCY <br /> Cl INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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. ❑ it. ❑ 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 ONLY <br /> COUNTY R JURISDICTION Al AGENCY N FACILITY ID N 1t of TANKS BI SITE <br /> ISM O k 10 Ito 1 o 1 Z <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE M WITH AREA CODE <br /> 01mg <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS <br /> S N FILED ❑ DATE FI E <br /> NO <br /> O <br /> rclFCy FIA(m <br /> l <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTp 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 ONL <br /> FS1RM A(3 288) <br /> �\�. DATA PROCESSING COPY <br />