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STATE OF CALIFORN!„ WATER RESOURCES CONTRIb-$OARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION mo p <br /> COMPLETE THIS FORM FOR EACY 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 ❑ 6 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 147/ <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SIT NAME CAREOF ADDRESS INFORMATION <br /> k-� <br /> ADDRESS / NEAREST CROSS STREET ✓COWWTIe ❑ PARTNBBIIP Cl FEI)E LAG <br /> min* _ D CDNPOLAiN7t1 ❑ O MM ADEN ❑ iF➢EMI AGENLY <br /> O ❑ IW7MONL ❑ QIUNIY#GESGY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> r ON CA <br /> TYPE OF BUSINE ISTRIBIfIOfl ❑1 PROCESSOR ✓Box ii INDIAN EPA ID N _ N of TANKY <br /> 5 OTHER RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION <br /> 3 FARM ❑ TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(UST,FIRST) PHONE N 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 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 indicate 0 PARTNERSHIP ❑ STATE AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRBSS 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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY11 JURISDICTION R AGENCY M FACILITY ID N of TANKS N SITE <br /> `1 <br /> _l J <br /> RRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> L <br /> MBER PERMIT ATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED <br /> YES NO <br /> CHC N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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,"-- <br /> FORM <br /> NLYfFORM A 13-2-SB) \ <br />