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STATE OF CALIFORNIA ``' WATER RESOURCES CONTROL BBl(RD V <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =� �� Z <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to II <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT <br /> CHANGE OF INFORMATION ❑ 7 PERMAN TLY CLOSED SITE <br /> MARK ONLY ❑ ❑ 6 TEMPORARY SITE CLOSURE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT <br /> (A� <br /> I.FACILITY/SITE INFORMATION &ADDRESS- (MUST BEGCOMPA14E OF DLETED)RESS NATION <br /> FACILITY/SITEN E <br /> ✓rya 0 PARTNERSHIP ❑ STAiE-AGFNLY <br /> NEAREST CROSS STREET � CGBNB4ilON 0 LGCpLAGEN-AGENC+ � FEOERAIAGENCY <br /> ADDRESS O ❑ INovou I 0 COUNTYAGENCY <br /> STATE ZIP CODE 5��� E�I AREA .JJ..(L GQD�7� <br /> CITY NAME CA <br /> EPA ID # Not TANKY - <br /> TYPE OF BUSINESS p RIBUTOR 4 PROCE& R ✓Box if INDIAN <br /> ❑ AT THIS SITE RESERVATION or ❑ <br /> F-11 GAS SIATION FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> p WITH AREA CODE <br /> DAYS NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) <br /> PHONE <br /> CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE it WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE p WITH AREA <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> i NAME <br /> S ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> MAILING or STREET ADDRESS 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> M.WITH AREA CODE <br /> STATE ZIP CODE <br /> CIN NAME ' <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to intlicate Cl PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION Cl LOCALAGENCYO FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <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. if. ❑ 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 a SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N IL -- N of TANKS at SITE <br /> a9 <br /> CURRENT LOCAL ADEN CY FAC SIDC{/Jx APPROVED B PHONE a WITH AREA CODE <br /> PERMIT NUMBER PERMIT AP ATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D TE FILED <br /> R � 3 � (p YES [-] NO <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N <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-BB) C <br /> DATA PROCESSING COPY J <br />