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- STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> _ SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH AGILITY/SITE °"�iFORN <br /> MARK ONLY Y ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SF <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILI ITE NAME CARE OF ADDRESS INFORMATION <br /> U <br /> ADDRESS /� NEAREST CROSS STREET ✓Box to Mcale ❑ PARTNERSHIP ❑ STATE-AGENC <br /> /OVV ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGE <br /> INDIVIDUAL ClCOUNTY-AGENCY <br /> � <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> i G�/✓ CA <br /> TYPE OF BUSINESS: F-]p TRIBLITOR ❑4 PROCESSOR -/Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER RESERVATION or ❑ TAT <br /> of HISSI LANDS THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> f✓� u <br /> MAILING or STREET ADDRESS ✓B to indicate 13 PARTNERSHIP ClSTATE-AGENCY❑ ORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCYJ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME � STATE ZIP CODE PHONE#,WITH AREA CODE <br /> c 3s <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 ❑ 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. ❑ it. 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 /> [al:� I I 1 -1 1 1 1 1 L I zf 10 F�IZ I 1 1 [-:4 <br /> CURRENT LOCAL A 4NCY FACILIT=1. APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER /vGK PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LO ATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FIL <br /> 3.�3 3a YES E] NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT#THI6o <br /> S 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 /> DATA PROCESSING COPY /' <br />