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SOF..TN <br /> STATE OF CALIFOROA WATER RESOURCES CONTROL YARD : <br /> FORM `A': m_ y� <br /> UNDERGROUND STORAGE TANK PROGRAM _�` �m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 4�IFpftNxP <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE SITE 1V <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE D <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 4 <br /> FACILITY/Sg NAME /v(' c l CARE OF ADDRESS INFORMATION <br /> ,4 J L <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 41100 C ❑ COMP JRATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> S DNIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA - <br /> TYPEOF USINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or �AT <br /> of TANK's ^ <br /> 1 GAS STATION ❑ 3 FARM ❑5 OTHER TRUST LANDS ❑ THIS SITE ."_.J{ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRS ' w^^ HONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME . ^ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS J\ ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> _— CITY NAME &C ZIP CODE PHONE#,WITH AREA CODE <br /> 111. 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 /> GIN 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. 11. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLED 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 /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS(TRAACCT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 4V a YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT T�ODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST III OR MORE TANK PERMIT FORM `B'APPLICATION(S), U S THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />