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STATE OF CALIFORNhq WATER RESOURCES CONTRocBOARD <br />FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br />SITE (� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />) J / COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 <br />ONE ITEM ❑ 2INTERIM PERMIT ❑ II AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />of .YS <br />SITE <br />FACILITY/SITE NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />CARE OF ADDRESS INFORMATION <br />k of TANKS at SITE <br />ADDRESS <br />/L• <br />uNEAREST <br />0 INDIVIDUAL ❑ COUNTY -AGENCY <br />CROSS STREET <br />✓ Bab TMO D PARINE/BRP 0 STATE-AGAGEN <br />❑ IYMPoPAII(IN ❑ LOL1L-AGBIC/ O FEGERAL-AGENCY <br />❑ INOMOUAI ❑ fAUV1Y4GEIiCY <br />CITY NAME <br />APP VED BV NAME PHONE F WITH AREA CODE <br />STATE <br />CA <br />ZIP CODE <br />l/3 <br />SITE PHONE #. WITH AREA CODE <br />TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR <br />I GAS STATION El FARM <br />❑ / PROCESSOR <br />❑ 5 OTHER <br />✓ Box if INDIAN <br />RESE❑ <br />TRUSTVLANDS ATION Gr ❑ <br />EPA ID N <br />PERMIT EXPIRATION DATE <br />AT THUS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />CENSUS "ACT 0 <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST FIRST) <br />PHONE N WITH AREA CODE <br />DAYS: NAME(LASTFIRST) <br />PHONE N WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE K WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />I/ Box to indicate D PARTNERSHIP 0 STATE -AGENCY <br />k of TANKS at SITE <br />0 CORPORATION D LOCAL -AGENCY 0 FEDERAL -AGENCY <br />0 INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE PHONE a, WITH AREA CODE <br />III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />✓Bol to indicate 0 PARTNERSHIP D STATE -AGENCY <br />k of TANKS at SITE <br />D CORPORATION 0 LOCAL -AGENCY 0 FEDERAL -AGENCY <br />D INDIVIDUAL 0 COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIPCODE PHONE p, 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. ❑ 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 S SIGNATURE) DATE <br />LOCAL AGENCY USE ONLY <br />U M <br />CCO77N <br />JURISDICTION R <br />AGENCY k <br />FACILITY ID P <br />k of TANKS at SITE <br />SII <br />'IFC, <br />�II�TY�/% <br />T <br />CURRENT LOCAL AGENCY FACILITY ID N <br />APP VED BV NAME PHONE F WITH AREA CODE <br />3lK <br />l/3 <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LOCATION CODE <br />CENSUS "ACT 0 <br />SUPERVISOR -DISTRICT CODE <br />BUSINESS PLAN FILED <br />DATE FILED <br />YES No <br />CHECKF <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPT <br />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 INFORMI ONLY. <br />FORM A (3-2-88) <br />DATA PROCESSING COPY / <br />