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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ice:• <br /> W <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� <br /> 01-1) COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ly7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM E:l 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE � <br /> � vT <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) p <br /> PAC I /SITE NAME CAREOFADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bc IonhE ❑ PARMERSHIP ❑ STATE-AGENCY <br /> / 13 CORPORATION ClLOCALAGBIO' E3FEDERAL-AGENCY <br /> V 1 ❑ INDMDIAL ❑ COUNW.AGBICY <br /> CITY NAME STATE ZIP CODE SITE PHONE S,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: F7 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION orF al TANK'S <br /> ❑ I GASBTATION 3 FARM 5OTHER TRUST LANDS ❑ ATTMISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE F WITH AREA CODE <br /> NIGHTS: NAME(UST,FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If 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 indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE F.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE F.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(T)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> I <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY F JURISDICTION F AGENCY F FACILITY ID F F of TANKS at SITE <br /> CURRENT LOCAL AGENCY FA UTY ID F APPROVED BY NAME PHONE F WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT* SUPERVISOR-DISTRICT CODE BUSINESS PUN NO ❑N❑FILED DATE FI i� <br /> OHECKS PERMITAMOUNTSURCHARGE AMOUNT FEE CODE RECEIPTS YBY: //Qp <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 0 Y. <br /> FORM A(3-2-88) <br /> /T �`�/ DATA PROCESSING COPY <br />