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STATE OF CALIFORNIP WATER RESOURCES CONTRAOARD <br /> FORM `A': _ �o Z <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION e I o <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ &RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM Y CLOSED SITE F"a <br /> ONE I M ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY ITE INFORMAT &ADDRESS— (MUST BE COMPLETED) N <br /> DD <br /> FACILITY/SITE NA E CARE OF ADDRESS INFORMATION <br /> Do( <br /> ADDRESS NEAREST CROSS STREET ✓8010,1dieate ❑ PARTNERSNP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LCCAL AGENCY 13 FEDERAL AGENCY <br /> ii t4w 17,61 11INDNIDUAL ❑ COUNTY AGENCY <br /> CITY NAME / A/ �P� STATCA 21P CODE SI/n/TE PHONE'n9-47 k31/AREA CODE 75-1/ <br /> TYPE OF BUSINESS: ISTRI TOR ❑ 4 PROCESSOR -/Box it INDIAN EPA ID x _ #of TANK' <br /> RESERs <br /> ❑ 1 GAS STATION Y3 FARM ❑ 5OTHER TTRUSTMATION LANDSo ❑ ATTHISSITE r <br /> EMERGENCY CONTACT PERSO PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: Ni(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N 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 lnGieate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUS7\'§E COMPLETED) <br /> NAME A/— RE OFADDRESS INFORMATION <br /> MAILING of STREET ADDRESS ox to indicate 11 PARTNERSHIP ElSTATE-AGENCY <br /> El RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ IN VIDUAL ❑ COUNTYAGENCY <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 NOTIFIC TION AND BILLING: I. 11. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST O Y KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# It of TANKS at SITE <br /> [w == X108 00 <br /> CURRENT CAL AGEIID IT APPROVED BY NAME PH E#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE TPERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODEES,PSN FILED NO ❑ DATE FID D <br /> 2 <br /> CHECK# PERMIT AMOUNT SURCHARTOFAMOZINT FEE CODE RECEIPT <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)t <br /> DATA PROCESSING COPY �� <br />