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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> a <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Io <br /> � COMPLETE THIS FORM FOR EACH,!. CILITY/SITE <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMR 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY LOSEDSITE <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) -4 <br /> O <br /> FACILI /SITE AME CARE OF ADDRESS INFORMATION <br /> ADDRESSNEARESTC SS STREET ✓Bms, C PAMNETSHIP D STATE ABDO <br /> �y ❑ OOFPDM70N D LOMAGBKY D HEI)EP LAGEIV <br /> D INDMWAL D COUNTY AGENCf <br /> CITY NAME STATE ZI CODE SITE PHONE#,WITH AREA CODE <br /> CA IQ05 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR4 P R ✓BDx#INDIAN EPA IO # <br /> a <br /> #of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHRESERVATION Efl TRUST LANDS ❑ AT THIS SITE ir <br /> EMERGENCY CONTACT RERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATI N & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS \ ✓Box to intlicate 1:1 PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate D PARTNERSHIP C STATE-AGENCY <br /> D CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BDTN OAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO E 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 If #of TANKS at SITE <br /> Od O_L gl!IE 101010101 <br /> CURRENT LQpAL AGEIICY FACILITY ID# APPROVED BV NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA ION CODE CENSUS cR TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI D <br /> 3 o\S YES E] NO 0 51151f9 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONL <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />