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STATE OF CALIFORNIO WATER RESOURCES CONTR"BIRD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM a Q z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , <br /> �a tiFa aN'� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY Elf NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMAN D SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CT? <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) I <br /> FACILITYISITE NAME CARE OF ADDRESS INFORMA ION <br /> irn <br /> ADDRESS NEAREST CROSS STREET ✓6 RPDAAL ❑ LOCAL�ACENCY ❑ FEDERAL-AGENCY <br /> 41 ❑ INDIVIDUAL I� WUNTY-AGENGr <br /> STATE ZIP DDE: SITE PHONE#.WITH AREA CODE <br /> CITY NAME CA <br /> L7 2 <br /> TYPE OF EI ESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR v"Box if INDIAN EPA ID # #of TANK's <br /> 1 GAS STATION [:] 3 FARM ❑ 5 OTHER El <br /> or ♦ /, �/� AT THIS SITE <br /> TRUST LANDS /��J/)�" <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> _ PHONE#WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> DAYS: NAME(LAST.FIRST) <br /> � <br /> tJ/ wY/{r �•�""'� — _4j PHONE#WITH AREA CODE <br /> NIGHTS: NAME{LAST,FAST) <br /> PHONE#WITH AREA CODE NIGHTS' NAME(LAS .FIRST) <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> lipMAILING ar STREET ADDRESS - ✓Box to Indicate TNERSHIP El STATE-AGENCY <br /> AD ElirCORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> EE INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> ✓Box to indicate ® PARTNERSHIP STATE-AGENCY <br /> MAILING or STREET ADDRESS <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(i)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ IIL❑ <br /> THIS FORM HAS SEEN 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# <br /> FACILITY ID# #of TANKS et SITE <br /> E0 <br /> Gr / <br /> APPROVED BY NAME PHONE k WITH AREA CODE <br /> CURRENT LOCAL AGENCY FACILITY ID k <br /> PERMIT NU BER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> BUSINESS PLAN FILED DATE FILED <br /> LOCAT/I/O/�N CODE CENSUS TRACTkSUPERVISOR-DIST Cf;IDE YES ❑ NO ❑ Q <br /> �/ ��CJ✓ BY: <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATIONI UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> RMA(3-2-158) <br /> 46 DATA PROCESSING COPY <br />