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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br />FORM `A': UNDERGROUND STORAGE TANK PROGRAM V �o <br />SITE EAeCILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />�/T/ COMPLETE THIS FORM FOR EACH FA kfTY/SITE <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 �PERMANENT D SITE <br />ONE ITEM F-]2 INTERIM PERMIT F -]d AMENDED PERMIT E]6 TEMPORARY SITE CLOSURE /; S WO I <br />I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />FACILITY/SITE NAME <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />✓Box toi0dicale ❑ PARTNERSHIP ❑ STATE -AGENCY <br />MAILING or STREET ADDRESS <br />= <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />ADDRESS <br />y( vel <br />NEAREST CROSS STREET <br />✓Rota iak ❑ PARTNERSHIP 11 STATE -AGENCY <br />q <br />? <br />❑ WICOIUTION ❑ LOGY AGENCY ❑ FEDERAL AGENCY <br />PERMIT NUMBER <br />❑ INDMDUAL ❑ CWNIYAGENCY <br />CITY NAME <br />PERMIT EXPIRATION DATE <br />STATE <br />ZIP CODE <br />CENSUS TRACT N <br />SITE PHONE N. WITH AREA CODE <br />_ <br />on <br />DATE FILL/ED <br />CA <br />3 � <br />TYPE OF BUSINESS'. 2 DISTRIBUTOR <br />d PROCESSOR <br />Box if INDIAN <br />EPA ID N <br />SURCHARGE AMOUNT <br />1 GASS7ATION 3FARM <br />❑ � <br />❑ 5OTHER <br />RESERVATION or E] <br />TRUST LANDS <br />_ <br />of TANK's <br />AT THIS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) <br />PHONE N WIT PE <br />DAYS: NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />%✓lC �%GrJiS <br />JDE <br />ecru/ <br />.S`�- / <br />5' <br />NIGHTS. NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />! <br />5c 4 <br />✓Box toi0dicale ❑ PARTNERSHIP ❑ STATE -AGENCY <br />MAILING or STREET ADDRESS <br />✓ 80x to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />= <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />CITY NAME <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE PHONE It, 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 />✓Box toi0dicale ❑ PARTNERSHIP ❑ STATE -AGENCY <br />R of TANKS at SITE <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERALAGENCY <br />= <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />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. 21, it. ❑ III. ❑ I <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 R <br />JURISDICTION d <br />AGENCYIL <br />FACILITY ID M <br />R of TANKS at SITE <br />3 9 <br />= <br />v t LI 3 � y a o c)/ <br />CURRENT LOCAL AGENCY FACILITY ID N <br />APPROVED BY NAME PHONE N WITH AREA CODE <br />/2GGgL <br />3.3 <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LOCATION CODE <br />CENSUS TRACT N <br />SUPERVISOR -DISTRICT CODE <br />BUSINESS PLAN FILED <br />DATE FILL/ED <br />3 � <br />YES NO <br />CHECK M <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPT N <br />BY: <br />x <br />00 <br />J <br />THIS FORM MUST BE ACCOMPANIED BY AT LFAST (1) OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. �-, <br />FORM A (3-2-86) <br />n r 0 " DATA PROCESSING COPY <br />