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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM _ '"" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �; o <br /> COMPLE HIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑S TEMPORARY SITE CLOSURE5� C" <br /> CD <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> L <br /> ADDRESSNEAREST CROSS STREET ✓I%a B nJrale D PWINERIF D SIATEAGENC( <br /> D COIPORATDN D LOLL-AGBWY [:I FEDERAL AGENCY <br /> CC C ❑ INON11 L D G(RO iAGENCY <br /> CITU NA E STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> oe CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Bo%#INDIAN EPA ID # #of TANK'# <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS a ❑ <br /> 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 /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY'NAME STATE ZIP CODE HONE It,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz fo indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY'NAME STATE ZIP CODE PHONE it.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. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> N� O <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE If WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDDATER D <br /> YES NO ❑ �� <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY' <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)01 MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL . �- <br /> FORM A(3 2-88) J <br /> ,r. DATA PROCESSING COPY -... / / <br />