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STATE OF CALIFORK k WATER RESOURCES CONTROL BOARD <br /> �i <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM uo - <br /> S7�" ) FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �Y l COMPLETE THIS FORM FOR H FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMITNGEOFINFORMATION ❑ 7 PERMANENTLY CLOSE F� <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT 6 TEMPORARY SITE CLOSURE T <br /> Ii <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) v <br /> N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS , NEAREST CROSS STREET ✓BMWfdoNI ❑ PMRF/9AP ❑ STATE AGENCY <br /> 30 CO MTIDN ❑ LOCAL-K00 ❑ FEDOSI-AGE10 <br /> ❑ INIWDLK ❑ COMP-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ y DISTRIBUTOR ❑ 1 PgOCESSOR ✓Box II INDIAN EPA ID N <br /> ❑ ❑ ❑ TRUST LANDS RESERVATION�F ❑ AT TH0 of IS SITE <br /> I GASSFATION 3 FARM 5 OTHER <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING a STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING m STREET ADDRESS ✓B.X to indicate ❑ 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 ADDRBBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING I. ❑ II. ❑ Ill.❑ <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 N AGENCY N FACILITY ID N N of TANKS at SITE <br /> ® = = I I I / 1 -71 F0 <br /> CURRENT LOCAL AGEY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> N <br /> PERMIT NUMBS PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION ODE NSUSTRACTN SUPERVISOR-OISTRICT ODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO E] <br /> CHECK PERMIT MOUNT SUR CHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)0R MORE TANK PERMIT FO R M -B' APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY �� J <br />