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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE .oxa`r <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) C <br /> FT;'T?AME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓gmmiM¢ea ❑ PARI)IMIF ❑ SIATE-AGEIKY <br /> / ❑ MDUOI-ON El IXIIIHIYGUIN 11PROW.-AGDO <br /> CY <br /> CITY NAME /� STATE ZIP ODE SITE PHONE N,WITH AREA CODE <br /> CA 53�o j <br /> TYPE OF BUSINESS ❑2 IBUTOR ❑1 PROCESSOR ✓BOX IF INDIAN EPA ID N <br /> RESERVATION or M o1 TANK'a <br /> ❑ t 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 N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.RRST) PHONE N 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 mclicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box Minoicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. ❑ 11. ❑ 111.❑ <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 /> CCOOU�NTY/N JURISDICTION N AGENCY N FACILITY ID N N o/TANKS at SITE <br /> IBJ <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 CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED BAT <br /> /�/FI <br /> � YES NO fY / <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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 /> FC W A(3-2-881 <br /> ATA PROCESSING COPY ._ <br />