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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 'E " "^ "` <br /> A <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �' r / " <br /> m� kL <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� to <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE I"� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> CD <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) ~ <br /> O <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> S <br /> ADDRESS NEAREST CROSS STREET ✓ 0 PARTNERSHIP 0 STATE AGM <br /> TON 0 LW&ASENCP 0 FEDEMIAGENLV <br /> IN)MWAL O GG.NIYIGENCr <br /> CITY NAME STATE ZIP CODE WE PHONE k,WITH AREA CODE <br /> -S- CA G509 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROC R ✓Box N INDIAN EPA ID p <br /> RESERVATION or N M TANK'k <br /> ❑ I GAS STATION ❑ 3 FARM THEA TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA GOOF DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> y �3 <br /> NIGHTS: N E(LAST.FI ) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDFW ✓Box to indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> / eiev� Z_� 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> /� 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boxtoinokate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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. ❑ it. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> ® = = In 10 1 EEaKlo 1 o © <br /> CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMR APPROVAL DATE LCODER <br /> ATE <br /> LOCATION CODE CENSUS TRACTk SUPERVISOR- (STRICT CODE DATE I D <br /> 2-3 <br /> U NO ❑ <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CEIPT k 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 88) <br /> DATA PROCESSING COPY <br />