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STAGE OF CALIFORNIA WATER RESOURCES CONTROAARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o , <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE `'��•oa"" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACJLRY/SI E NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS r NEAREST CROSS STREETffi <br /> ❑ PARTNERWIP 0 STATE AGENCY <br /> RON 0 LOCAL AGENCY 0 FEDBVL-AGENCY <br /> ❑ INDMDUN 0 WUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> C- �D✓� CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4P E55OR ✓Box R INDIAN EPA ID M <br /> RESERVATION or N of TAMC. <br /> ❑ 1 GASSTATION [:] 3 FARM OTHER TRUST LANDS ❑ AT1 SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> CRL7 — <br /> NIGHTS: NAME(LAST,FIR T) ROCHE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET DRESS ✓ olndicate 11 PARTNERSHIP - 11 STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> A 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAMESTA E ZIP CODE TPHONE N,WITH AREA CODE <br /> v <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME ^` CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS v ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ 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)BOX INDICATING WHICH ADM ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 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 S JURISDICTION N AGENCY E FACILITY ID R M 01 TANKS N SITE " <br /> CURRENT LAM AGENCY FSPILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED q./.}i <br /> YES NO <br /> CHEC N PER IT AMOUNT 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 IS A CHANGE OF SITE INFORMATION ONLY.- <br /> FORMA(3-2-88) �� • . � \ <br />