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ar <br /> STATE OF CALIFORM9 WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMIiID SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION <br /> OCAL <br /> ADDRESS ` r NEARE ROS TREET ❑✓00wot ilON 0 LARRY IP OAGENCY ❑ STFE �4GE <br /> LWANCY <br /> CITY NAME STATE ZIP cbbE SITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS 2 DISTRI OR 4 PROCESSOR ✓Box if INDIAN EPA 10 N RESERVATION or _ It of TANK s <br /> ❑ AT THIS SITE <br /> 1 GAS STATION FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(12MARY) 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) HONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &A6PRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (M TBE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to nichcone ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ST E ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WNICH ABOVE ADDMU SHOULD BE USED FOR BOTH LE NOTIFICATION AND BILLING: I. ❑ II. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TH BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY R FACILITY IDR Rot TANKS N SITE " <br /> m 0 I a � � d <br /> CURRENT LOCAL AGENCY FACILITY ID NAPPROVED Y NAME p f� PHONE N WITH AREA CODE <br /> a 'i y r� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION GATE <br /> LOCATION CO E CENSUS TRACT R SUPERVISOR-DISTRICT CODE BUSINESS RAN FILED DATE FILED <br /> O^C YES [] NO <br /> CHECK R PERMIT AMOUNT SU AMOUN <br /> AROE T FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICA71011 ), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-SB) <br /> `x owe <br />