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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD QZ <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAMSITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> CCOMPLETE THIS FORM FOR EACH FACILITY/SITE1 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT PliCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE Ha <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAM CARE OF ADDRESS INFORMATION cn <br /> ADDRESS NEAREST CROSS STREET ✓9Rbigrale PAWNNW 0 STATE MOO <br /> 0 COPCRICION 0 LOCI-AGEXCI 0 FWM AGDO <br /> CITY NAME 0 '/M <br /> NDK 1:1COUNttA CY <br /> STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> PE OF BUSINESS. CA <br /> TYPE 2 DIS OR ❑4 PROCESSOR I ✓Box it INDIAN EPA ID x <br /> ❑ 1 GAS STATION ❑3 FARM ED OTHER TpUSTVLANDS or ❑ - Aof <br /> AT THHISIS SI SITE <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 p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION 81 ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intli.ate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE LIP CODE PHONE R.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 11STATE-AGENCY0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> [STATE 21P CODE PHONE p,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE 11)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 A SIGNATURE) DATE <br /> LOCAALTAGENCY USE ONLY <br /> COUNTYjs—/—' JURISDICTION N AGENCY# FACILITY IDN of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID F APPROVED By PHONE F WITH AREA CODE <br /> U <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> rCHECK <br /> CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE <br /> YES NO , <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTA <br /> 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 INFO ATION ON <br /> FORM A(3.2-BSi <br /> ._. DATA PROCESSING COPY ...i <br />