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STATE OF CALIFORNIA") WATER RESOURCESCONTROLSOARD s <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> CCOMPLETE THIS FORM FOR EACH FACILITY/SITE "--"- <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> Q <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FAC ITE NAME • CARE OF ADDRESS INFORMATION <br /> /J <br /> ADDRESS I NEAREST CROSS STREET ✓Rw Io ird.l# ❑ PARTNERSHIP ❑ S7A7E AGENCY <br /> 3 T <br /> El CORPORATION 11 LOCAL AGENCY ❑ FEDEML AGENCY <br /> —{� ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP�ODE� SITE PHONE#.WITH AREA CODE <br /> CA (/�S <br /> TYPE OF BUSINESS2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID # #of TANK'# <br /> ❑ ❑ 5 OTHER RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GASSTATION ❑3 FARM ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boxtci t)IcTt. ❑ PARTNERSHIP 11STATE-AGENCY <br /> E3❑ CORPOAAIN [I LOCAL-AGENCY FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING Dr STREET ADDRESS ✓Box to,,dicaie ❑ PARTNERSHIP 0 STATE AGENCY - <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ 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# JURISDICTION If AGENCY# FACILITY ID# If of TANKS at SITE <br /> 22 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> ©(Xoti! 3l <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION GATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL D <br /> YES NO E 3 Z N <br /> CHECK# PERMITAIAOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:L-1 <br /> ur4 <br /> V <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST("OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FO M A(3-2-BS) hh <br /> `✓ DATA PROCESSING COPY #M/ u <br />