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STATE OF CALIFOF"IA WATER RESOURCES CONTROL BOARD pR <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM =`ter o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE c��irp aN <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT li�r5 CHANGE OF INFORMATION ❑ 7 PERMANENTI Y.CLOSED 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 /> t� <br /> ADDRESS NEAREST CROSS STREET ✓Boy to mrate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> I „/J y� C--Le, <br /> I ❑ CORPORATION ❑ COUNTY-AGENCY ❑ FEDERAL AGENCY <br /> C / C--L r / ❑ INDIVIDUAL ❑ CAUNTY-AGENCI' <br /> CITY NAMEr__ / STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> 0 <br /> S`r G CA <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ ❑ � <br /> RESERVATION <br /> of ❑ k of TANK' O <br /> I GAS STATION 3 FARM 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 k WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION X ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ 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 — ( UST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LE11AL NOTIFICATION AND BILLING: 1. ❑ II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TOT BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION S AGENCY k FACILITY ID k If of TANKS at SITE <br /> CURRENT LOCAL ADEN Y FACILITY ID k APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED �J//�/ <br /> 3 YES ❑ NO ❑ A ! (� ! , <br /> CHECK K PER IT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. / <br /> RM A(3-2-BB) <br /> 1 <br />