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STATE OF CALIFORNIO WATER RESOURCES CONTROSOARD 5`'.�.•. ��, <br /> FORM `A'. u <br /> _ UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> f1�i <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �' ..o■ <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SIT15 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �— <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) -3 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATICN <br /> ADDRESS� C� I NEAREST CROSS STREET I/3o.Io+arale ❑ 4RTNERS)4 ❑ STATE AGENCY <br /> 4 � [:1 :ORPORATON Cl -OCµAGENCY CC] �EOERAL AGE NC co GE.CY <br /> �. 1 ��-�,^• ✓' U NUI410UA1 ❑ ;,"U'N iY�A N <br /> CITY NAME STATE ZIP CODE SITE PHONE 4.'NITH AREA CODE W <br /> CA <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ /PROCESSOR ✓Box t INDIAN EPA ID 4 <br /> R1:1ESERVATION or k of TANK'S <br /> ❑ I GAS STATION 117 FARM ❑ 5 OTHER TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST.FIRSTI PHONE 4 WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE 4 WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE 4 WITH AREA CODE NIGHTS. NAME(LAST =1RST1 PHONE 4 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 na.cate C PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4.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 ina.cale ❑ PARTNERSHIP C STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 ADORESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY M FACILITY ID II K of TANKS at SITE <br /> mEl I I I I F/ L <br /> lr/ <br /> T1 _ <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE 4 WITH AREA CODE <br /> p r-<' r Jh <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION COOL' CENSUS TRACT 1 SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED I <br /> YES ❑ NO ❑ ��r� ID�-�.Yi1 <br /> \ CHECK 4 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 4 BY: <br /> THIS FORA MUST BE ACCOMPANIED BY AT LEIST(1)OR MORE TANK PERMIT FOR M IS' APPLICATION(S). UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> \\ t <br />