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STATE OF CALIFORN IT WATER RESOURCES CONTROL BOARD .`iu Of..,lNF <br /> FORM FA': ', <br /> UNDERGROUND STORAGE TANK PROGRAM =" a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE fV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ID <br /> O <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> G <br /> ADDRESSNEAREST CROSS STREET ✓B.Modi.P ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ClCORPORATION 11 LOCAL EIFEDERAL AGENCY <br /> �+ �Ci.� ❑ INDIVIDUAL ❑ COUNT AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE# WITH AREA CODES <br /> ?J G CA <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER If of TANK's 13 TRUST VLANDS ATION NF ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS14'S. NAAM•INtM�(LAST.FIR <br /> NIGHTPHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IVIE- EE( TLFI T) PHONE If WITH RARE ODE 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 lointlicale ❑ PARTNERSHIP Cl STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> V(C <br /> MAILING or STREET ADDRESS ✓Box to,,,ocate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> = = 1 . <br /> CURRENT LOCAL AGENCY FA ILII` ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> \\an CHECKa PERMIT AMOUNT SURCHA AMOUN FEE CODE YES ❑RECEIPTtkG ❑ BY: <br /> Y \ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(MORE TANK PERMIT FORM 'B'APPLICATION(S), UN HIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />