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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> E�� T <br /> r1;• <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE �/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY rl ngFD SIT <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) ~ <br /> FACILITY/SITE NAMY CARE OF ADDRESS INFORMATION <br /> ADDRESS r- NEAREST CROSS STREET ✓Box to Wale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> L._ ., D �� f7i� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> �`; ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME- STATE. ZIP CODE SITE PHONE M,WITH AREA CODE <br /> C�� ( CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID M <br /> N of TANK't <br /> RESERVATION or <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE I7 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMAT ( ST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate [I PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,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 M JURISDICTION M AGENCY#I FACILITY ID M M of TANKS at SITE <br /> Ehl LLLlI t� I Li T_ 11 <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBERPER MIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILED I n / <br /> YES ❑ NO ❑ cY <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M - <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 /> FORM A(3-2-88) I <br />