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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRE:S .y NEAREST CROSS STREET ✓Bm Or*& D PAAMMP 0 STAR AGENCY <br /> D G(XPOPANGN D LDGI�AG NCY 0 FEDERAL AGENCY <br /> ❑ IN MDIAL D CWNIYAGENCY <br /> CITY NAME / / STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 1 P ESSDR I '/Box A INDIAN EPA ID N a of TANK s <br /> ❑ t GAS STATION ❑3 FARM OTHER TRUSTYATION LANDS or 1:1AT TRIS 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 N WITH AREA CODE <br /> ,[ j-'e rvv 0�0 — / <br /> NIGHTS: NAM LAST,F7) PHONE/WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORkIlkTION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to i,dicale 0 PARTNERSHIP D STATE AGENCY <br /> D CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRE — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP D STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CXECK ONE(1)BOX INDICATING WHICH ABOVE ADORES[SHOULD BE USED FOR BOTH LE NOTIFICATION AND BILLING: I. ❑ II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO T4E BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a AGENCY a FACILITY ID If a o/TANKS at SITE " <br /> DoJ - <br /> CURRENT LOCAL AGENCY FACILITY ID O APPROVED BY NAME PHONE a WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOC TTI N C DE CENSUS TRACT SUPER YI R-DISTRICT CODE BUSINESS PLAN FILED DATE FI D <br /> YES ❑ No ❑ a <br /> CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N <br /> THIS FO 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 <br />