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STATE OF CALIFORNPA WATER RESOURCES CONTROZ BOARD <br /> FORM `A': <br /> SITE UNDERGROUND STORAGE TANK PROGRAM u <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m.. _ . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM ❑2 IN ❑ T PERMANENTLY CLOSED SITE <br /> INTERIM PERMIT IV <br /> ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE CO <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/ T NAM <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> NEAREST SSSTFIEET io <br /> RTNERSHIP 0 STATE-AGENCY <br /> CALAGENCY 0 FEOEWAGENCY <br /> CITY NAME STATE OUNTY AGENCY <br /> 2 CODEE#,WITH AREA CODE <br /> TYPE OF BUSINESS. CA <br /> ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box#INDIAN EPA ID N <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHFA TRUSTYtANDS ATION or ❑ #of TANK'#T THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDAgY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 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 intlicale ❑ PARTNERSHIP 13ORATION0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 13 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIPCODE PHONE N,WITH ARE_CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> O CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ n. El 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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID S If of TANKS at SITE <br /> A <br /> CURRENT LOCAL AOENCY FACILITY ID k APPROVED BY NAME PHONE#WITH AREA CODE <br /> M - D <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATT CODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESSYES PLAN FINO E]LED FILED �� �O <br /> CHECK# 3 PERMIT AMOU4NNT(T SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS'S A CHANGE OF SITE INF RMATION ON , <br /> FORM A(3-2-88) - �J <br /> #Wa� DATA PROCESSING COPY d/ <br />