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- T .-, _ •r,r.Ti 11,. r �`,�a �,.i�s. .T'kA ..z'-. ;,..:r t:%:f.i' ^s"'f - r + •��«r ry � t,g �.,�. hi.-,�?. �^� a�,.��.- <br /> 4 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND'STORAGE TANK PROGRAM <br /> SITE CILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACT /SITE +FpRK P <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) ; <br /> FACILITYISITE NAME fCARE OF ADDRESS INFORMATION <br /> Z7 t_0 <br /> ADDRESS NEAREST CROSS STREET ✓8mmirdCMe ❑-PMTNU&IP ❑ STATE-AGDV <br /> ❑ t;OR R TON ❑ LOCAL-AGENCY ❑ FEDEAALAGENCY <br /> ❑ iNDMOLIAL ❑ COUNTY-Amoy ' <br /> CITY NAME _ STATE ZIP CODE SITE PHONE 0,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID x <br /> ❑ ❑ ❑ TRUSTRESERLANDS <br /> ATION or ❑ of T IS SITE GAS STATION 3 FARM 5 OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> t DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) - PHONE#WITH AREA CCOE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS- NAME{LAST,FIRST) PHONE#WITH AREA CODE <br /> i <br /> 4 II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME: CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY' <br /> CITY NAME STATE ZIP CODE PHONE R.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 Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 4 ' <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: 1. ❑ IL ❑ Ili.❑ <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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COmNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> I 7_1 Ll <br /> i <br /> El <br /> l / . <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME _ PHONE#WITH AREA CODE <br /> I A0 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 r� YES ❑. NO ❑ 3�1 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT. FEE COOS RECEIPT# BY <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM .B'APPLICATION(S),UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-89) - Y <br /> '' DATA PROCESSING COPY <br />