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STATEOF F, CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> f FORM 'A': to <br /> .,r UNDERGROUND STORAGE TANK PROGRAM =�'�' <br /> -.:�... <br /> 4-SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> f COMPLETE THIS FORM FOR EACH FACILITY/SITE `'�•o«N`' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) N <br /> FACILITY/SITE ME CARE OF ADDRESS INFORMATION 00 <br /> M� <br /> ADDRESS, NEAREST CROSS STREET ✓Bar to iidi* ❑ PMTNM W ❑ STATE AGENCY <br /> 1 ❑ ❑ LOCAL-AGENCY ❑ FEDENAL•AGE10 <br /> C3'INa ❑ CUM-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF INESS ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box B INDIAN EPA ID N <br /> �ATION ❑3 FARM ❑5 OTHER TRUSTESERVLANOS or ❑ If of TAN�Sl� <br /> AT THIS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 4 <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> i� <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST 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 N,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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME„ 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: 1. ❑ II. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 3 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY . <br /> COUmNTY M JURISDICTION M AGENCY M FACILITY IDM (/#of TANKS at <br /> El I I LLL I 9t �3!;_*y I I <br /> 1---�--.1� v <br /> l () I <br /> CURRENT LO AL AGENCY FACILITY IDN APPROVED BY NAME PHONE M WITH AREA CODE <br /> C-a 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO Q 6 <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <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 ONLYC <br /> FORM A(3-2-88) _ J <br /> 4 <br /> DATA PROCESSING COPY <br /> *7 ' �,• <br />