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STATE OF CALIFORNIO WATER RESOURCES CONTRAOARD `a <br /> FORM A': <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> qlP <br /> COMPLETE THIS FORM FOR EACH AGILITY/SITE <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF IN <br /> ❑ 7 PERMANENTLY CLOSED SITE —4 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 <br /> CD <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) CD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> RSHIP 0 STATE AGENCY <br /> ADDRESS 0 NEAREST CROSS STREET O Bm IopAAiIGN ❑ LGCANEAGENCY ❑ FEUEAALAGENCY <br /> NpIVIpUAI ❑ GGUNNAGENGY <br /> CITY NAME STATE ZIP CODE SITE PHONE II,WITH AREA CODE <br /> IP�rV CA 531a(o <br /> TYPE OF BUSINESS I—I EPA ID If <br /> 2 pISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN M of TANK's <br /> ^�✓/ RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST FIRST) <br /> PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE k,WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> M� <br /> -/Box to RATIle Cl PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS <br /> El CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> CITY NAME <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. ❑ it. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY IDN If of TANKS at SITE <br /> cm <br /> CURRENT LOCAL AGENCY FACILITYID# <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT N BER KK PERMIT APPROVAL DATE PERMIT EXPIRATION GATE <br /> LOCA CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDDATEFILE <br /> oc ,p��J ✓�Cl/ YES NO E] <br /> CHECK# PERMIT AMOUNT SURCHARGEAMOUNI FEE CODE RECEIPT IT 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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />