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STATE OF CALIFORNh, o <br /> WATER RESOURCES CONTS BOARD <br /> FORM 'A': a <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> ;o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °+�„o ,r• <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM 7 PERMAN OSED SITE F-a <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ��� <br /> L FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED � <br /> FACILITY/SITE NAME ) <br /> w <br /> CARE OF��DRESS INFORMATION <br /> ADDRESS <br /> N R STC SS STREET ✓Buwmiate 0 PARTNERSHIP 1:1 STATE AGENCY <br /> l ` D EA pVI- n — ❑ CORPORATION ❑ LGCALAGENCY EDEAAL- ENCY <br /> CITY NAME / ❑ INDIVIDUAL ❑ CAUNIV-AGENCY <br /> STATE ZIP COD S'ITTE PHO E# I H REA CODE <br /> TYPE OF BUSINESS: p DISTRIBUTOR �4 PROCESSOR ✓Box if INDIAN EPA D #A � ZB �[�� ?� <br /> ❑ ` /^ #of TANK's <br /> I GAS STATION 3 FARM 5 OTHER RESERVATION Or TRUST LANDS ,v 'V <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME( ST FIRST) �] HONE#WITH AREA CODE DAYS' N ME(LAST,FIRST) <br /> PHONE If WITH AREA CODE <br /> NIGHTS: NA E T.FIRST) /JL*lZ PHONE p WITH AREA7CODE NIGHTS: NAME LAST FIR <br /> S �# ST) P O E#WITH AREA CODE <br /> N <br /> D !° <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAM CAR OF ADDRESS INFORMATION <br /> MAILING or$TRp ADDRESS /Box la Intlicate ❑ PARTNERSHIP <br /> O(/! N ❑ CORPORATION ❑ LOCAL-AGENCY STATEAGENCY <br /> ❑ INDIVIDUAL 0 COUNTY- E ERAL- GENCY <br /> CITU NAME AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> A CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP <br /> ❑ CORPORATION 0 LOCALAGENCY <br /> 0 STATE-AGENCY <br /> CITY NAME <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY 0 FEDERAL AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ED it. If. <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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION R AGENCY R FACILITY ID IT <br /> #o/TANKS at SITE <br /> 3 <br /> CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAM <br /> (/ ,/CKY_'I.Z lqtG 47 <br /> F/ PHONEM WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED <br /> oz- ;-? 3, �`-� 1 YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODEl W <br /> RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PER FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-8B) <br /> DATA PROCESSING COPY <br />