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STATE OF CALIFORNIJO WATER RESOURCES CONTROAARD � <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> _ m Z <br /> SITE <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION „oRN,p <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY <br /> MARK ONLY F-1CLOSED SITE N <br /> Up <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) GJ <br /> CARE OF ADDRESS INFORMATION <br /> FACILDY/SIT M <br /> NEAREST CROSS STREET ✓Bwb nOrak ❑ PARTNERSHIP ❑ CTATEAGENC! <br /> ADDRESS /l 11 COMM RAElLDGU-A NY 101FEDE0.4L AGENCY <br /> ❑ INDMDIIAL [I COUNTY <br /> AGENCY WITH <br /> 7 /G STATE ZIP CODE SITEPHONEY,WITH AREA COD <br /> CITY NAME San,//w <br /> EPA ID AN X of TANK'a <br /> TYPE OF BUSINESS: F-12 DISTRIBUTOR ❑ 4 PROCESSOR /Box il INDIAN RESERVATION or AT THIS SITE <br /> ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS' NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> ,klf//IP� � 2 � /U>neS R � <br /> NIGHTS: NAME(LAST F ST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRS <br /> PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED)E OF <br /> [NAMERESS N ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENGV <br /> G or STREET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENGV ❑ FEDERAL-AGENGV <br /> �A ❑ INDIVIDUAL ❑ COUNTY-AGENCY/ STATE ZIP CODETH AREA C00EAME <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED)CARE OF ADDRESS DN <br /> NAME <br /> ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> MAILING or STREET ADDRESS ElCORPORATION LJLOCAL-AGENGV Cl FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N.WITH AREA CODE <br /> CITY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL IN <br /> AND BILLING: I. II. ❑1 III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> of TANKS at SITE <br /> COUNTY# JURISDICTION# AGENCY N <br /> FACILITY ID# # <br /> � o D <br /> am <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> APPROVED BY NA y PHONE N WITH AREA CODE <br /> PERMIT NUMBER <br /> C�\ PERMIT APPROVAL DATE PERMIT PIRATION DATE <br /> GATE FIL <br /> LOCATION CO CENSUS TRACT# SUPERVISOR-DISTRI ODE BUSINESS,SN FILED NO <br /> DFEE CODE RECEIPT# BY: <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT <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 <br /> FORM A(3-2-88) <br /> ` � DATA PROCESSING COPY <br />