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STATE OF CALIFORNIA WATER RESOURCESCONTR91BOARD Ax <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION b o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F'a <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5� <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) 00 <br /> I-� <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 5/- s <br /> ADDRESS NEAREST CROSS STREET ✓BRyy»be_IP 0 PARTNERSHIP 13STATE AGENCY <br /> GORPORATION 0 LOCAL AGENCY 0 FEDERAL AGENCY <br /> ❑ <br /> INDIVIDUAL 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> ��'nc_k_401j CA 9sao3 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box it INDIAN EPA ID # <br /> ❑ ❑ ❑ TRUSRESETVLANDS or <br /> ❑ AT THIS SITE <br /> 1 GAS STATION 3 FARM 5 OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If 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 /> MAILING or STREET ADDRESS I/Box to lntlkale 0 PARTNERSHIP ❑ STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 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 ✓50.to lntlicale Cl PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION At AGENCY# FACILITY ID# Al of TANKS at SITE <br /> ® � ko, g u0oo <br /> CURRENT LOCAL AGENCY FACILITY ID 0 APPR ED BY NAME? PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT It SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED n <br /> 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 ON <br /> RMA(3-2-88) <br /> f DATA PROCESSING COPY <br /> L <br />