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STATE OF CALIFORNO WATER RESOURCES C NTRO <br /> O UCBOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq�FORN P <br /> MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE !"A <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE3 —4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) cy) <br /> FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> T a l — <br /> ADDRESS NEAREST CROSS STREET ✓Box tointli ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> i- ❑ TION ❑ LOCAL-AGENCY El FEDERAL-AGENCY G ! / G4 INDIVIDUAL 1:1 COUNTY-AGENCY <br /> CITY NAME l STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> Lock e 740r c/ CA 0/-S-0 3-7 <br /> TYPE OF BUSINESS: ❑ 2 DI OR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID #RESE #of TANK'a <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUSTVLANDS ATION or ❑ C AT THIS SITE v <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ,9 T <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bo dE]inicate PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPORATION 1:1 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box tPOate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> rR'IN61VIDUAL 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. 11. ❑ 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# —7 #of TANKS at SITE <br /> DE] EI 02 / I_lc_)1_jl <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE <br /> ��t/c 13 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> / CHE�k� PET AMOUNT SURCHARGE AMOUNT FEE CODE YES NO <br /> 8O ❑ 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 <br />