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STATE OF CALIFORNI'A'N WATER RESOURCES CONTR&BOARD "^l'.{ <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM " o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �"�� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE (03 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) O <br /> N ' <br /> FACILII Y/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRE53� ` NEAREST CROSS STREET ✓,Rarmiar#e ❑ PAATNEASHIP ❑ 5fAtE-AGENCI' <br /> YI ogmTNM' ❑ IDDM.AGENCY ❑ FEDUK AGBICY <br /> rl ❑ INDPADUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA q5 `IO <br /> TYPE OF BUSINESS 2DISTRIBUTOR 4PROCESSOR ✓BDaif INDIAN EPA IDN _ If of TANKS <br /> ❑ 1 GASSTATION TI <br /> ❑ 5 OTHER TRUSTVLANDS or ❑ AT THIS SITE <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,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME DARE OF ADDRESS INFORMATION <br /> RA - py-Epi <br /> MAILING or STREET ADDRESS ,'gootto iodicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY sa#y <br /> L _ 4. 11 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#,WITH AREA CODE <br /> bnc4 '1 0� s <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S t'-e <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 It.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. II. ❑ 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 /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS At SITE <br /> ® = = - � <br /> CURRENT LGCAL AQENJ.Y PACTY N APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER I//� (rJ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK <br /> DE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED <br /> X13 . YES NO (0—�gC( <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> III 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 /> �V FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />