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STATE OF CALIFORNI WATER RESOURCES CONTR ._,JARD <br /> FORM `A': UNDERGROUND STORAGE ANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EAC F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PE&M16NTLY CLOSED 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 CARE OF ADDRESS INFORMATION <br /> �.ti�s r � ��, 6>7 <br /> ADDRESS NEAREST ROSS STREET ✓BaxIDWiC0 ❑ PPMNEMIP ❑ STATE-AGENLY <br /> 2q / I n ❑ COimRATIQf! ❑ LOENC! [3FEDERhL-AGENGI <br /> L/.�1�(/•'/��,f•"`G �(� ❑ INOMDUAL ❑ COUNTY <br /> -N1Y�AGENCY <br /> CITY NAME STATE ZIP COD SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDI EPA ID b N of TANK'rs <br /> RESERVATION or AT THIS SITE <br /> 1 GAS STATION 3 FARM E]5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LA=6) <br /> PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> qie 'I 14"3r_ S(? <br /> NIGHTS: NAME(LAST,FIRST) PHONE R WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE it WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF DDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP - ❑ STATE-AGENCY <br /> ❑ <br /> CORPORATION ❑ LOCAL-AGENCY ❑ PEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE q,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE CO PLETED) <br /> NAME CARE OF AkOORESS INFORMATION <br /> MAILING or STREET ADDRESS ✓B x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ JRPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ I DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE S.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. ❑ 11. ❑ 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&SIGNATUREI DATE <br /> LOCAL AGENCY USE ONLY <br /> FPERMITNUMBER <br /> JURISDICTION S AGENCY P FACILITY ID P P of TANKS at SITE <br /> 0aD01 0o NCY FACILITY ID• APPROVED B NAME PHONE A WrrH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT f SUPERVISOR-DISTRtCT CODE BUSINESS PLAN FILED DATE FILED <br /> Z YES NO �%r/�-PERMIT AMOUNT SURCHARGE AMOUNT FEE DE RECEIPT 1 BY: <br /> THIS FORM MUS BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B' ICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> (FORM <br />