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. . ,c 77 ,. <br /> STATE OF CALIFOR11A WATER RESOURCES COAL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'AirowSt�" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMA OSED�ITE/ F'a <br /> ONE ITEM ❑ p INTERIM PERMIT E] 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> (b <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) C <br /> FACILITY/SITE NAM CARE OF ADDRESS INFORMATION <br /> ADDRESS ///� NEAREST CROSS STREET ✓E@tY Irdlute ❑ PAWNEPSPIP ❑ STATEAGENCY <br /> xe W✓ w ❑ COPPoMTION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNT(AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE n,WITH AREA CODE <br /> LtL c CA <br /> TYPE OF BUSINESS: ❑p DI RIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA Ion <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑5 OTHER TRUSTVLANDS ATION or ❑ #oI TANM# <br /> AT THIS SI <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) / <br /> DAYS'. NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It 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 INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE n,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL O COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.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. ❑ I. ❑ 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 M FACILITY ID# If o1 TANKS at SITE <br /> m = = ) 1 10 U <br /> CURRENT LOCAL A NCY FACILITY ID k APPROVED BY NAME PHONE M WITH AREA <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> YES ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT f/_ <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 ONL . <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY , <br />