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STATE OF CALIFORNP WATER RESOURCES CONTRIBOARD <br /> FORM 'A': <br /> ° <br /> SITE UNDERGROUND STORAGE TANK PROGRAM FACILIT <br /> /1 Y/SITE, INFORMATION and/or PERMIT APPLICATION m <br /> COMPLETE THIS FORM FOR EACH FA SITE <br /> MARK <br /> / <br /> c9[IFOR�P 1� <br /> MARK ONLY ❑ 1 NEW PERMIT3 RENEWAL PERMIT <br /> ONE ITEM 5 CHANGE OF INFORMATION 7 PERMA Y CLOSED SITE <br /> 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT Pel <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE CO❑MPLETED)EMPORARY STEaosuRE 3 <br /> FACILITY/SITE NAME IV <br /> S , CARE OF ADDRESS INFORMATION V <br /> ADDRESS <br /> 1G/ �� <br /> / o NEAREST CROSS STREET ✓Bor to iMiyle <br /> FlCORPORATION El LOCAL AGENCY ❑ FEDERAL <br /> ARTNERSHIP 0 STATE AENCY <br /> CIN NAME AGENCY <br /> STATEZIP CODE INDIVIDUAL ❑ COUNIYAGENCf <br /> ? SITE PHONE p,WITH AgEA CODE <br /> TYPE OF BUSINESS: 02 RIBUTOR E] 4 PROCESSOR ✓Box if INDIAN EPA DaA <br /> 1 1 GAS STATION 3 FARM 5 OTHER RESERVATION or <br /> TRUST LANDS ❑ #of TANK'# <br /> EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE <br /> DAYS NAME(LAST FIRST) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) <br /> �- let PHONE#WITH AREA CODE <br /> NIGHTS: NAME((LAST, ST) '-- , <br /> - PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PNAROPERTY MOWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> E <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> ✓Box to Icale ❑ PARTNERSHIP ❑ STATE- <br /> ❑ ORATION ❑ LOCAL-AGENCY AGENCY <br /> CITY NAME NDIVDUAL ❑ FEDERALAGENCY❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> '/50.lOate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> PRA <br /> ❑ CTION E3LOCAL-AGENCY ClFEDERAL-AGENCYCITY NAME INDIVDIV DUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N.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# AGENCYLI FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE Al WITH AREA CODE <br /> Y <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TTRAC-�T#-� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> CHECK# PERMIT AMO T SURCHARGE MOUNT FEE CODE YES RECEIPT#G ❑ BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST f+iOR MORE TANK PERMIT FORM 'B'APPLICATION($), US THIS IS A CHANGE OF SITE INFORMATION ONLY. II <br /> 1 FORM A(3-2-88) itC <br />'N/ I -S�O DATA PROCESSING COPY �\ <br />