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or-. <br /> STATE OF CALIFORNIJP WATER RESOURCES CONTRCROARD <br /> FORM 'A': _ <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION a <br /> L�F00.i,P <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY F-1I NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PE biAkki J3 CLOSED SITE <br /> ONE ITEM El INTERIM PERMIT ❑ 4 AMENDED PERMIT 1:36 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS o1 E <br /> OSS STREET p� �TI�N �AOC��i O FEl1ERA AGFNd <br /> Gj� �AG A� Uti Cl INOmowL ❑ COUNT_AGENcv <br /> CIN NAME 21P CODE / SITE PHONE p,WITH AREA CODE <br /> SS (� <br /> TYPE OF BUSINESS'. ❑ p pISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIA EPA ID x R of TANK'Y <br /> RESERVATION r ❑ AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> EMERGENCY CONTACT PERSON(PRIMARY) <br /> DAYS. NAME(LAST,FIRST) <br /> PHONE it WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTSNAME(LAST,FIRST) <br /> PHONE At WITH AREA CODE NIGHTS' NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> CIN NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NO <br /> AND BILLING: I. El If. ❑ III. Ll <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) GATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION R AGENCY N FACILITY ID R Rol TANKS Bl SITE <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> CURRENT LOCAL AGENCY FACILITY IDN 6 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSU>v AACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ❑i."/ <br /> . DTE FILED O <br /> YES NO 1� <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 /> ORM A(3.2�88) v • <br /> Q1 \O i <br />