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STATE OF CALIFORA WATER RESOURCES CONTROL BOARD /s< <br /> W. <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION b <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE vN`" <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT -5'CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSUREC/ <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> ACILITY7SITE NAME CARE OF ADDRESS INFORMATION <br /> fxBQRE55 :NEAREST CROSS STREET ✓Box load to ❑ FAAPERw ❑ STATEAGENCY./ /1 — ❑ COQR�AiTION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY—t. C--. INOUAL ❑ COUNTY-AGENCYCITY NAME E ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA73`1 C <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID k <br /> ❑ 1 GAS STATION ❑ 3 FARM , OTHER TRUSTYLANDS or ❑ AT <br /> HIS SITE 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 AREACODE <br /> F <br /> L <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & 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 Cl 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 or STREET ADDRESS Be.✓ to indicate PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE CODE I PHONE k.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. ❑'SII. ❑ 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 B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION# AGENCY# O<, FACILITY ID# #of TANKS at SITE <br /> m = = O <br /> C T LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE k WITH AREA CODE <br /> ,PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE ED <br /> YES NO A <br /> CHECKMPERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> HIS 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 /> ORM A(3-2-88) . 9 <br /> FILE COPY <br />