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STATE OF CALIFORN6.. WATER RESOURCES CONTROCBOARD 't '"0' <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM A, Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : l o <br /> COMPLETE THIS FORM FOR EACCILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE IJ <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) ~ <br /> t0 <br /> FACT TY/SITE NAME CAREOF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bmbir#ima ❑ fANfNBHIIP ❑ S1A1E'AGDO <br /> Cf�I!oS S, /VE ❑ NDMOIIALM ❑ YAGENG'EICY ❑ FEOEPAI#GFTCY <br /> CITY NA STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> / f I CA 'S <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID # If of TANK' / <br /> TRUSFIESETLANDS Or <br /> ❑ / <br /> ❑ I GAS STATION FARM ❑5 OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA ODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST.FIRST( PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> � N <br /> MAILING^o�r STREET ADDRESS ✓Box to indicate 13 PARTNERSHIP El STATE-AGENCY <br /> pC/�S ❑ ION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 12 INDIVIDUALEl COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> l Qx � 5 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Be.tointlieme ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <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. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION if AGENCYJT FACILITY ID# #of TANKS at SITE <br /> 1-1 o 10 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE If WITH AREA CODE <br /> C� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> CAT�f,ODE CE0 TRAM 8UPE OR-DISTRICT CODE BUSINES Y S[—] NG ❑ DAT E�ECK# PERMIT AMOUNTS SURCHARGE AC/MOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(SI, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> / FORM A(3B&) <br /> W/ -ZyF DATA PROCESSING COPY <br />