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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE <br /> F CILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•aa"'" <br /> MARK ONLY F-11 U 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE O <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE s <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) W <br /> FACIU ITE NAME CARE OF ADDRESS INFORMATION <br /> kV <br /> W <br /> ADDRESS NEAREST CROSS STREET ✓BNpYdial, Cl PMT*YSHP 0 STATE AGENCY w' <br /> I .,, D 0DIPWPATION D LOCA-AGDO 0 EEOEI&AGENCY <br /> 10 4S- L'\ 1 ❑ INWMWAL ❑ ODUNlY AGENCf <br /> CITY NAME I STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> w CA <br /> TYPE OF BUSINESS: F72 DISTRIBUTOR F—] 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or k of TANK's <br /> ❑ I GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N 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 ✓Box to indicate D PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> D INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box to indicate C PARTNERSHIP 0 STATE-AGENCY <br /> D CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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# AGENCY# FACILITY ID# If of TANKS PI SITE <br /> CU ENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PER IT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N�f� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED (,L, <br /> 2 Z2 � YES NO � Z �� O <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 IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-BB) <br /> '�O DATA PROCESSING COPY �j <br />