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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARDS v" <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =� Z <br /> o. . to <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o ;e <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT FD 3 RENEWAL PERMIT <br /> 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> N <br /> I.FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> [FACILITY/SITE NAME CARE OF ADDRESS INFORMATION w—l`ESS NEAREST CROSS STREET ✓8atwnQule ❑ P NERRIIP ❑ SfAiEAGENLY❑ CgIPO LOGL�AfiENLY ❑ EEOERALAGENGYS� y 7 /Vu ❑ cauNn 6B aSTATE ZIP CODE SITE PHONE N.WITH AREA CODE NAME dCA � �OF BUSINESS 2 D OR 4PROCESSOR ✓Box it INDIAN EPA IDN ` Mof TANKY <br /> RESERVATION or � � AT THIS SITE <br /> 1 GAS STATION FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> TH <br /> DAYS: NAME(LAST,FIRST) PHONE N WIAREA CODE DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Box to Eicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> NDIVIDUAL ❑ 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 Box eicate EI PARTNERSHIP ClSTATE-AGENCY <br /> ❑ RPORATION [ILOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH A80VE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. Il. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY S JURISDICTION S AGENCY* FACILITY 10 M M of TANKS H SITE <br /> � = = I I I q1 <br /> CURRENT LOCAL AOENyIY FAC( ITY I N � APPROVED BY NAME PHONE N WITH AREA CODE ISI <br /> PERMIT NUMBER //vim PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIILLED- <br /> 17 C9 3c/3 �.�. YES ❑ NO ❑ (£� <br /> CHEC N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: w <br /> NLYFOTHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE( RrNATION ONLY,,— <br /> FORM <br /> RM A(3-2-88) <br /> DATA PROCESSING COPY <br />