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STATE OF CALIFORNIA WATER RESOURCES CONTRObWOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE /�/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> iR <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �""O"� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Ix CHANGE OF INFORMATION ❑ 7 PERMANENTLY rl rygED SIT <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/ ITE NAMV CARE OF ADDRESS INFORMATION <br /> > v <br /> ADDRESS r NEAREST CROSS STREET ✓BRoiquV ❑ FAIRW MW D STATEAGDO <br /> ° CgrP13 WLIGN ` reAmc,❑ FEmR+LY <br /> w-AG <br /> o wri <br /> CITY NAMEL�dSTATE ZIP CODE SITE PHONE N,WITH AREA CODE r, CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID N <br /> RESERVATION or X of TANKS <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST.FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST FIRST) PHONE N WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to irftal. D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY Cl FEDERALAGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to mcl,cale 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 N,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: I. ❑ it. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION X AGENCY X FACILITY ID X X of TANKS RI SITE <br /> m 6 3 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DA FILE <br /> YES NO ❑ c <br /> CHECK f PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT f <br /> raNNaaaaaa <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(3-2-88) <br /> .r 1 <br />