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-r <br /> /� { <br /> WATER RESOURCES CONTROARD <br /> O '/5 t '•Thf <br /> FORM "A": <br /> UNDERGROUND STORAGE TANK PROGRAM -o --, <br /> `� `' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - .; i a <br /> ' COMPLETE THIS FORM FOR EACH FACILITY/SITE `9c FoaN r <br /> FONfIARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F-] 7 PERMANENTLY CLOSED SITEE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE qe <br /> L7 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) ? <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ,✓, BBpCWcata ❑ PARTNERSHIP E] STATE-AGENCY <br /> LIVCORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE SIT PHON N,WITH AREA CODE <br /> CA 77- <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESE❑ ❑ ❑ TRUSTLANDSATION or ❑ #of HIS SI <br /> 1 GAS STATION 3 FARM 5 OTHER 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 N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 41. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRE ,.✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> L-J CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY J STATE ZIP CODE PHONE N,WITH AREA CODE <br /> q v� <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 N,WITH AREA CODE <br /> Id. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ACOVE ADDnims SHOULD BE USED FOR DOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11- 1:1 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 8.SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> [M I I I I Ll I I I I I /h� M E I I E <br /> C RENT LOCAL AGENCY FACILITY IDN APPR Y NAME PHONE#WITH AREA CODE <br /> PIPERMIT NUMBER JPERM�ITAPPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO ❑ , <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> FORM A(3-2-88) <br /> ,Qt�y DATA PROCESSING COPY <br />