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STATE OF CALIFORNsrc WATER RESOURCES CONTRM BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM _" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I O z <br /> d: / <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑-Y PERMANENTL-VSED SITE f..a <br /> ONE ITEM E]2 INTERIM PERMIT ❑4 AMENDED PERMIT ID6 TEMPORARY SITE CLOSURE / �) <br /> I. FACILITY/SITE INFORMATION III <br /> I �A,D'D�R'-ESS (MUST BE COMPLETED) t0 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Un <br /> ADDRESS NEAREST CR OSS STREET ✓Pm NidraV ❑ PANTNENRIIP ❑ STATE AGVCr <br /> ❑ C4RPIXUTIM O LOCAL-AGENCY ❑ FEDE W AGENCY <br /> ❑ INDVIOUN 11CWNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS' ❑2 DISTRIBUTOR <br /> ❑4 PROCESSOR ✓Box it INDIAN EPA ID N <br /> ❑ 1 GAS STATION ❑3 It <br /> FARM ❑ 5 OTHER TpLSTYLANDS A ION dT ❑ AT THIS SITE �. <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE#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 ADDRESS ✓8dx to indicate ❑ PARTNERSHIP 11 STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bon to Ind,cate Cl PARTNERSHIP El STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 13FEDERAL-AGENCY <br /> CITY NAME <br /> ClINDIVIDUAL ElCOUNTY AGENCY <br /> STATE ZIP CODE 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. it. ❑ 111.❑ <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 INIII JURIIS��DICTIIION B AGENCY N II(�I� FACILITY ID R k of TANKS BI SITE <br /> r. <br /> CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE Y WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL <br /> YES NO <br /> CHECK E PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT F BY <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMR FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) \ ( <br /> DATA PROCESSING COPY <br /> J <br />