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Nil <br /> STATE OF CALIFORNIA � WATER RESOURCES CONTROt60ARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> _m,.. to <br /> SITE FACILITY/SITE, INFORMATION and/or, PERMIT APPLICATION o ;e <br /> COMPLETE THIS FORM FOR EAC 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 CY) <br /> C" <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) f0 <br /> FACILITY/SIT NAME CARE OF ADDRESS INFORMATION <br /> b `� <br /> ADDRESS NEARsT <br /> CROSS STREET 0✓DWRATION O IGMCK.AGEEY O RME STATEAIGAGENO <br /> ❑ INGMWAI ❑ CWN1V#GENCI <br /> CI NAME STATCODE SITE PHONE N,WITH AREA CODE <br /> A 533b <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box B INDIAN EPA ID N _ k of TANK'N <br /> ❑ 1 GAS STATION 3 FARM ❑ <br /> 5 OTHER RESERVATION or ❑ 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#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(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 ✓Bax to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NA / CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A,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: 1. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY S JURISDICTION N AGENCY R FACILITY ID N R of TANKS at SITE <br /> CURRENT LOCAL AOR CY ACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> ODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS,SNFILED NO ❑ DATE FILED <br /> PERMIT AMOUNT SURCHAR AMOUNT FEE CODE RECEIPT <br /> �V THIS FORM MUST BE ACCOMPANIED BY AT LEAST(7)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />