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STATE OF CALIFORNIA - WATER RESOURCES CONTROL-dbARD <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/ r PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT IV 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE All <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAMEpp CARE OF A ESS INFORMATI N <br /> �ON lAc <br /> ADDRESS NEARES C O TREET ✓Bmbigiole ❑ PAATWITSNIP ❑ STATE AGENCY <br /> SrCIMD AWL ❑ O7UNIYAUNC ❑ R EPA#GENY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA,CODE <br /> CA �'� - 2- 9 <br /> TYPE OF BUSINESS: ❑2 RIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN <br /> EPA ID p <br /> RESERVATION of AT <br /> TANSY <br /> ❑ I GAS STATION 3 FARM ❑ S OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It 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 -/Box to inEicate ❑ PARTNERSHIP - ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE$1,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 inEicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDIM SB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. pr II. ❑ 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 /> COUmNTY N JURISDICTION R AGENCYII R of TANKS ISLSITE <br /> CURREN CAL AGENCY FACILITY ID N APPROVED BY NAME "ONE It WITH AREA CODE <br /> PERMIT NU OVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTIIICT CODE BUSINESS PLAN FILED DATE FIjLE <br /> �Z '�. _ YE8 NO 9 <br /> CHECR N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 40 BY:e7 IL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. _ <br /> FORM A(3-24B) !^ \ <br />