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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAMA <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I 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 <br /> w' <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FA CI IN/SITE NAME CARE OF ADDRESS INFORMATION <br /> Tn"On <br /> ADDRESS NEAREST CROSS STREET ✓3or.b nErNe D FANTNENSHP D STUE-AGEN.Y <br /> ❑ MNDBATIGN D LOC&-AGENCI D FEMIALAGRILY <br /> ❑ INWIDI)k D WUNIY AGENCY <br /> CITY NAMESTATE ZIP ODE SITE PHONE 0,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p N of TANK'F y'1 <br /> RESERVATION or ❑ AT THIS BITE (_f <br /> ❑ 1 GAS STATION ❑3 FARM <br /> :15P <br /> 5 OTHER TRUST(ANDS <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#WITH AREA CODE NIGHTS'. NAME(I-AST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME .,w^o, CARE OF ADDRESS INFORMATION <br /> MAILINGSTREET ADDRE k/Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> Cl CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> Lal D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAM STATE 21P CODE 1 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 D PARTNERSHIP D STATE AGENCY <br /> D CORPORATION D LOCALAGENCYD FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK 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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY41 JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> ENT L CAL AGENCY FACILI ION ROVE PHONE N WITH AREA CODE <br /> a <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEgr <br /> 0 _C/1 / YES NO /YJ /(� <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: 11/ <br /> 1 J <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 ONL . <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />