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STATE OF CALIFORNIA' WATER RESOURCES CONTROYBOARD <br /> SN�e �Mp <br /> w <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION7"` <br /> 1 LJ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �'=''�"-" <br /> MARK ONLY ❑ 1 NEW 11MMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION .❑,"ERMANENTLY CLOSED SITE F-A' <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I--i <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> CIl <br /> FACILITY/SITE NAME -� CARE OF ADDRESS INFORMATION <br /> Y <br /> 1 <br /> ADDRESS NEAREST CROSS STREET ✓Bm binNuk 0 <br /> ❑ <br /> STATE AGE� <br /> Cl fTION ❑ LXALA(iEC11 FEMW-A(IE <br /> Y <br /> El :imlcuu ❑ aTY NCExa <br /> CITY NAME . STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> v CA I i <br /> TYPE OF BUSINESS: [__j y DISTRIBUTOR ❑ PROCESSOR ✓Box it INDIAN EPA ID If <br /> ❑ 1 GAS STATION 3 FARM 5 OTHER RESERVATION or N of TANK'sG-- <br /> [:] E] TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bae to,,d,cate ❑ PARTNERSHIP ❑ 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 w STREET ADDRESS ✓Box 1.lydcale Cl PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <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)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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 S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If ISI' AIIGEN�CY# I� FACILITY ID N N of TANKS at SITE <br /> / <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE N 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 FILED <br /> YES El NG E] 7104 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE PECEIPTY B <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> \FORMA(3@-68) G <br /> DATA PROCESSING COPY ,J\ , <br />