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STATE OF CALIFORNIA WATER RESOURCES CONTROL9ARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r ` ! � <br /> a� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> fn <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 72_ ENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 7 9 <br /> ADDRESS NEAREST CROSS STREET ✓k4o indicale ❑ PARTNERSHIP ❑ STATE-AGENCY N <br /> 3 L olc `fie` CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY .:"0 <br /> SEl ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE (� <br /> Gk CA 15t? a5 <br /> TYPE o USINESS: � p DISTRIBUTOR ❑ 4 PROCES7RESERVATION <br /> ✓Box if INDIAN EPA ID # <br /> or #of TANK's <br /> GAS STATION ❑ 3 FARM ❑ 5 OTHERRUST LANDS — AT THIS SITE <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 /> N <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> /VA <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bex to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> (❑ INDIVIDUAL El <br /> El COUNTY AG NCY ElFEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> a6)/ K <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> K © C- ii <br /> MAILING or STREET ADDRESS V/1 ,!LV I ' ✓Box to indicate ElPARTNERSHIP ElSTATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IID i 1 APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS RACT# SUPERVISO c-DIS TR� CODE BUSINESS PLAN FILED ❑ DATEILED <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> 7] <br /> MEN <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASWR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />