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STATE OF CALIFORNIK WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ao <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY LOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S3 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE AME CARE OF ADDRESS INFORMATION <br /> ADDRESS c NEAREST CROSjSTFjEET L ✓tImio eddie ❑ PAAiNOW Q STATE AGDO <br /> ❑ CORPORATION ❑ LOCAL�AGENp Q FEOEMLAGENCY <br /> ❑ INDNIWAL ❑ COUNIKAGBIp <br /> CITY NAME ^ 7 STATE h SITE PHONE N,WITH AREA CODE <br /> CA (/ <br /> TYPE OF BUSINESS 2 DISTRIBUTOR 4 ✓Box if INDIAN EPA ID N S of TANICa D <br /> ❑ I GASSTATION ❑ 3 FARM ❑ OTHE RESERVATION or <br /> or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> OAY NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> ao <br /> NIGHTS: NAME(LAST. ST) PHGfiE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORiIIIIATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Q CORPORATION Q LOCAL-AGENCY Q FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADD ESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Q LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> t <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS, <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADM$$SHOULD BE 6`41)FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJ Y,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION M AGENCY R FACILITY ID N N of TANKS at SITE <br /> M= 1 1 E01— <br /> CURRENT L <br /> ]jk <br /> PHONE N WIT71 AREA CODE <br /> PERMIT NUMBERPERMIT APPROVAL DATE RATION DATELOCATION CODESUPERVISOR-DISTLAN FILED DATE FILED <br /> aS ❑ NGCHECK a SURCHARGE AMORECEIPT N <br /> aaaaaaa <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. -1 <br /> FORM A(3-2-BB) \ /� <br /> W �' <br />