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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 9" °:'• <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ` <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �- <br /> �"cnonw' <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE r <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑q AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> � I <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) IV <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS � edNEAREST CROSS STREET ✓IW NYv1 Me 0 PARTNERSHIP 0 STATE.AGENCI <br /> 3Z 0 0DWIunON 0 LGCAEAGENCY 0 EEXIMIAGENLY <br /> 0 Nwmlwu 0 MUTYAGENIN <br /> CITY NAME STATE ZIP CODE / SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR /PROCESSOR ✓Box ii INDIAN EPA ID N <br /> ❑ RESE <br /> I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVATION LANDS or ❑ N of TANKS <br /> 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 N WITH AR FA CODE NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME K CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ApDRESS ✓Box to intlicate Cl PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 31 ID00 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME ^ STAT ZIP CODE PHONE p,WITH AREA CODE <br /> I <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toinaicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY ❑ FE - CY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N ITH 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 I RUE AND CORIhECT. <br /> I <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE N WITH AREA CODE <br /> i <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 476 YES ❑ NO <br /> CHECK If PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> \ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(q OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATIONOI(LY. <br /> ORM A(3-2-88) / / <br /> �-! DATA PROCESSING COPY � `/l/\ <br />