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STATE OF CALIFORNI.0 WATER RESOURCES CONTROILROARD P 5�'°"';"r"•�s <br /> FORM `A': �- a <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACT /SITE, INFORMATION and/or PERMIT APPLICATION Y �' I <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE "(FOR"P <br /> MARK ONLY 19 1 NEW PERMIT ❑ 3 RENEWAL PERMIT HANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1'� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE '10 ] CD <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) CSD <br /> 0© <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEA ST CROSS STREET ✓ mndicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> tff CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> G Q ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME �� STATE ZIP CODE PHON #,WITH AREA CODE <br /> CA �� v 9sek-030 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID #RESE #of TANK's <br /> ❑ 1 GAS STATION ❑3 FARMER TRUST LANDS ATION�r ❑ <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: N E(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) P ONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FlfiStT , PH NE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE q WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS _✓�ox to indicate 1:1 PARTNERSHIP ❑ STATE-AGENCY <br /> .,/ t✓J CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ©, 7l ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE#,W)[H AREA CODE <br /> 2c� <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME S 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: 1. ❑ 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 /> rPER <br /> UNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ILL I <br /> T LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> �6 O 02 <br /> UMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> N CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILED <br /> '0 3 YES ❑ NO <br /> 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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br /> i <br />