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STATE OF CALIFORNIP WATER RESOURCESCONTROLBOARD <br /> FORM `A': a � s; <br /> UNDERGROUND STORAGE TANK PROGRAM 7o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION °. z <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ITE }� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 <br /> CJl <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) Ca <br /> Jh. <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 41(2 <br /> ADDRESS F� • NEAREST CROSS STREET ✓BodoiMicale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> S' /O� qq��//LI� ❑ CORPORATION ❑ LOCAL ❑ FEDERAL AGENCY <br /> Am NII".-' Cl INDIVIDUAL C COUNNAGENCY <br /> CITY NAME STATE P CODE SITE PHONE#,WITH AREA CODE <br /> CA 3 <br /> TYPEOFBLISINESS. 2 ISTRIBUTOR ❑ 4PROCESSOR ✓Bo%if INDIAN EPA ID # <br /> ❑ i GAS STATION [P'3 FARM ❑ 50THER RESERVATION or - If of TANK's <br /> TRUST LANDS ❑ ATTHISSI <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE it 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 /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP C STATEAGENCY <br /> C CORPORATION ❑ LOCALAGENCYC FEDERALAGENCY <br /> ❑ INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM / CARE OF ADDRESS INFORMATION <br /> G <br /> MAILING or STREET ADDRESS ✓Box to'nd,cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> C CORPORATION C LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL C COUNTY-AGENCY <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. II. ❑ 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 N, JURISDICTION R AGENCY# FACILITY ID# If of TANKS at SITE <br /> LlCURRENT LOCAL AGENCY F6plLlrY ID A APPROVED BY NAME PHONE Jr WITH AREA CODE <br /> LU1 Q5 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED OAT )I D <br /> 3 YES NO � <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY I <br />