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STATE OF CALIFORNIA WATER RESOURCES CONTRO&ARD <br /> W a <br /> FORM 'A': 0 <br /> UNDERGROUND STORAGE TANK PROGRAM ='� ' '.L^ <br /> SITE FACILITY/SITE, INFORMATION and/or PE IT APPLICATION �� <br /> COMPLETE THIS FORM FOR EACH F LITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 U LY 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/SITENA CARE OF ADDRESS INFORMATION <br /> F l nl Sim A41 <br /> ADDRESS NEAREST CROSS$TSEET ✓BmmirAcale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPOM70N 0 LOCAL ❑ FEDERAL AGENCY <br /> ❑ ]NO DUAL Cl COUNTYAGENCV <br /> CITY NAME STATE <br /> ZIP CODE SITE PHONE x,WIT�IF- CODE <br /> CA —�35—0�7 <br /> EPA ID p <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR Rx/Box if INDIAN ESERVATION or ❑ N of TANK'N <br /> ❑ 1 GAS STATION ❑ 3FARM ❑ 5OTHER TRUSTLANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N 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 /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL AGENCY <br /> 0 INDIVIDUAL Cl 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. ❑ 11. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE <br /> 'LOCAL AGENCY USE ONLY <br /> �I T' TI <br /> C� JURISDICTION <br /> mJ AGEI�1� FACILITY IDN N of TANKS Al SITE <br /> / 13 1 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-131 CODE BUSINESS PLAN FILED DATE FILED <br /> YES [:]CHECK N 6 3 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTNIf [j If <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 /> FIR A(3-2-BS) 9 0 <br />