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EPSTATE OF CALIFORN� WATER RESOURCES CONTR�OARD �wTh <br /> S <br /> ..:..- i <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACHF CILITY/SITE FORN\R <br /> 14a I <br /> C4�IP <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S� <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) I a <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> G 14 ` <br /> ADDRESS NEAREST CROSS STREET ✓Box to rwicate Cl PARTNERSHP ❑ S,ATE-AGENCY N <br /> ❑ CORPORATION Cl LOCAL-AGENCY Cl FEDERAL-AGENCY CIO <br /> I �-K• Cl INDIVIDUAL ❑ COUNTY-AGENCY CJI <br /> CITY NAME STATE ZIP ODE SITE PHONE#,WITH AREA CODE <br /> G q CA S <br /> TYPE OF BUSINESS: ❑ qSTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ ❑ ❑ TRUSTLANDSATION or ❑ / /V / c #of HIS SITE 1 GAS STATION 3 FARM 5 OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> AIA <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME C i 0 r CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME � STAZI�OPHONE#.WITH AREA <br /> 111. TANK OWNER INFO MATION &ADDRESS — (MUST BE COMPLETED) C <br /> a 4 <br /> NAME ��/) C Se <br /> ��,CCARE 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#.WITH AREA CODE <br /> C Ll ICA q-1-19261 <br /> IV. LEGAL NOTIFICATIO'N' 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> ENUMBER <br /> JURISDICTION# AGENCY# _F�1CIL+TY fO — #of TANKS at SITE <br /> EEO I I I - I L I AaQ I :),I / 1 01Q O <br /> EHCY-FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> C <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEDvZ 3 /� YES ❑ NO ❑ gyp- <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> 1 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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY S <br />