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TATE OF CALIFORNIA WATER RESOURCES CONTROL oJARD A: <br /> \Sy <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM W�` x�m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE caliFpRN P <br /> F <br /> ARK ONLY [211NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITENE ITEM -4❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME �..0 CARE OF)DDRESS INFORMATION <br /> W <br /> ADDRESS _� —} NEAREST CROSS STREET �✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �./ �,,,�� /,q Z^ ! CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> a !/'SIL` L ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME-� STATE ZIP CODE SITE PHON #,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> �(1 GAS STATION 3 FARM 5 OTHER RESERVATION or / AT THIS SITE r <br /> I I ❑ ❑ TRUST LANDS ❑ /V <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHON N WITH AREA CODE <br /> NIGHTS: NAM ry <br /> Si,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE 9F ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> JEl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> ci <br /> CITY NA STATE ZIP CODE PHON #,WITH AREA CODE l 'll <br /> I11. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or S REET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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. Er it. ❑ 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 /> ` <br /> LA-� il I I I J E �� 1 (--) l 1 (:,E] () 10 7 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPR VAL RATE PE MIT EXPIRATION DATE <br /> 31za 7 <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED <br /> t // 5 YES NO <br /> ICHECK'# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# B : <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) <br /> DATA PROCESSING COPY <br />