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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 ' ,./ o 0 <br /> COMPLETE THIS FORM FOR EACH,FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT [—]6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) Co <br /> CD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET I/SO n N&InV D PMTNERSNP D STATE-AGUXY!I �� /L� V D INGIWWTilON O �AGENCY D FEDSW AGENCY <br /> vImk <br /> CITY NAME 1-1 <br /> CA ZIP CODE SITE p,WIT ARE%CODE <br /> � <br /> TYPE OF BUSINESS: S 3 <br /> ❑ 2 DISTRIBUTOR ❑/PR ESSOR ✓Box if INDIANAN EPA ID N <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUSTESEYLANDS ATION oY ❑ 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 N WITH AREA CODE <br /> NIGHTS', NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING of STREET ADDRESS ✓Box to,naw.w D PARTNERSHIP D STATE AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D 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 or STREET ADDRESS ✓Box w,i d,cate D PARTNERSHIP D STATE AGENCY <br /> D CORPORATION D LOCALAGENCYD FEDERALAGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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- ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY.# JURISDICTION R AGENCY# FACILITY 10# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY F LITY ID F APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> Z 3 0 2 Z YES ❑ NO ❑ g 12- U <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT( BY/ 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 <br /> low DATA PROCESSING COPY <br /> lWlx � `fes <br />