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STATE OF CALIFOAA WATER RESOURCES CONTROL BOARD <br /> zEP` <br /> FORM 'A': ; <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0) <br /> CD <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITEICn <br /> NAME CARE OF ADDRESS INFORMATION <br /> n (incl F. <br /> ADDRESS NEAREST CROSS STREET ✓B Wicate ❑ PARTNERSHIP ❑ S-ATE AGENCY <br /> Asa x/ a ^p ORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> /vlu h ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITU NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> R/ on CA <br /> TYPE OF BUSINESS: ❑ p DI IBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID # <br /> ❑ I GAS STATION [2"3FARM ❑ 5 OTHER RRRUSTVLANDS or ❑ It of TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA OODE <br /> n 13,IED f .709-k6 9 -! / SGnUt <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE it WITH AREA CODE <br /> 5geAe <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �J�✓+f �Gr <br /> MAILING or STREET ADDRESS Be.✓ to'o,icate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CC��99PRORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCYS. C1eNDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> ,F's ca &- A I 9573 / <br /> III. 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 Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY'AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.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. ❑ if. 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# FACILITY ID# #of TANKS at SITE <br /> ffm <br /> ILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 1OVAL DATE PERMIT EXPIRATION DATE <br /> TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 ;Q_ 3 � YES NO <br /> AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT It BY; <br /> C� <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 /> W\ <br /> FORM A(s-tea) DATA PROCESSING COPY <br />