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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM = <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCL P4 <br /> ONE ITEM ❑Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) O <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Sm to inac#e 0 PARrussmi, D STATE#Gm <br /> IDZ D CORPORAPON 0 LOCAL-MOD 0 RDEIUL-AGENCY <br /> D INOMDUAL D COIATY AGENCY <br /> CITY NAME STATEZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: p DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID p #of TANK. <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ATION o ❑ AT THIS STYE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#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,FIRST) PHONE#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 intlicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate 0 PARTNERSHIP D STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ 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 /> COUNTY# JURISDICTION# AGENCY# FACILITY ID Al #o1 TANKS at SITE <br /> ele-r I R-I ar I I I Io <br /> CURRENTnLOCAL AGEN�iCY FACILITY ID If APPROVED BY NAME PHONE At WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRAY --#_ SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED GATE F O <br /> Z7. O �_ YES <br /> CHECKk PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 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.(` V <br /> FORM A(3-2-88) v \ <br /> MaF DATA PROCESSING COPY <br />