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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> a <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT E6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY DSITE IV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �� <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY ITE NA CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓B.lI nI ❑ PARINERWP ❑ STATE AGENCY <br /> ❑ CORMMTDN ❑ EDC>L AGENC( ❑ FEDERAL AGENCY <br /> INDIVIDUAL <br /> CITY NAME STATE CODE SITE PHONE#, WITH AREA CODE <br /> CA S b q 33 - a <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 P ✓Box it INDIAN EPA ID k <br /> RESERVATION or #of TANK'a <br /> ❑ I GAS STATION ❑ 3 FAAM THEfl TRUST LANDS ❑ 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 /> a ao R 3 3- A3 <br /> NIGHTS: NAME(LA ,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl 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: 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 If AGENCY# FACILITY ID If If of TANKS at SITE <br /> ® = = I I 1a3 � <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> r 5-1-1 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ❑ DATE'Fla� <br /> 4 3 YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION 01 <br /> FORM A(3-2-88) \�J <br /> 1, / 95_ l I a�� DATA PROCESSING COPY �i <br />