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STATE OF CALIFORNIA WATER RESOURCES CONTROLGARD <br /> , <br /> FORMA A :/ <br /> UNDERGROUND STORAGE TANK PROGRAM ) <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> n i <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT Q5 CHANGE OF INFORMATION ❑ 7 PERM CLOSED SITE <br /> ONE ITEM ❑ 2 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 /> a 0Gib <br /> ADDRESS NEAREST CROSS STREET ✓Bm bnEiob Cl PARINUSNP 0 STAIEAGFNLT <br /> L ❑ N&MD <br /> 7 L 0 CommTON 0 LGGL AGBA.Y Cl FEDEM AWO <br /> IUL 0 caNnaGRlcr <br /> CITY NAME STATE ZIP CODE SITE PHONE If,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 tpa6p ✓Box if INDIAN EPA ID N If of TANK's <br /> RESERVATION ar ❑ AT THIS SITE <br /> ❑ I GAS STATION ❑ 3 FARM OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMA'ilfDN & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to inClcate 0 PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRE — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to idicale Cl PARTNERSHIP ❑ STATE AGENCY <br /> Cl CORPORATION Cl LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> C INDIVIDUAL 0 COUNTY-AGENCY <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 SDTH 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 /> APPLICANTSNAME(PRINTED&SIGNATURE) \ DATE <br /> LOCAL AGENCY USE ONLY \i <br /> COUNTY N JURISDICTION N AGENCYN, FACILITY ID N N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBERLKERMITAMOUNT <br /> RMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATO CODE SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED OATS FILEDYES NO SURCHAROE AMOUNT FEE CODE RECEIPT F Vf <br /> \\\1 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-SB) <br /> V <br />