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STATE OF CALIFORNIA WATER RESOURCESCONTROV-BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 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) <br /> FACILITY/BRE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓CommTK D FARNLOCAL <br /> PRIIP D STATEFIEDOI L ENCY <br /> ACEI <br /> ❑ COP0UAL ❑ ccumGENLY ❑ FEOEPAI AfiQICY <br /> ❑ IIIDY1gALL ❑ COUNTY#('BICE <br /> CITY NAME / STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> K CA Jr <br /> TYPE OF BUSINESS. p DISTRIBUTOR /PROCESSOR ✓Box if INDIAN EPA ID N _ N of TANKS <br /> RESERVATION <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TTRUSTT LANDS m ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE S WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE Al WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE S 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 inolcate D PARTNERSHIP Cl STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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',xicate 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 M,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ASOVR ADDRESS SHOULD BE USED FOR MOTH LEM NOTIFICATION AND BILLING: 1. ❑ If. ❑ 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 R JURISDICTION 1f AGENCY R FACILITY ID R S of TANKS N SITE " <br /> m <br /> CURRENT LOCAL AGENCY FACILITY D N APPROVED BY NAME PHONE A WITH AREA CODE <br /> PERMIT MBER PERMIT APPRO TE , I PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SU RVISOR IBTRI4 BUSINESS PLAN FILED DATE FILED <br /> 7717 YES ❑ NO <br /> CHECK N PERMIT AMOUNT R AGEANO FEE CODE RECEIPTS 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 A(3-2-1p) / <br />