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STATE OF CALIFORNI10 WATER RESOURCES CONTRAOARD •'� '""`^ ''f,. <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM = ' m <br /> SITE L FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION < <br /> COMPLETE THIS FORM FOR EACH FACIL /SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 2_5`CHANGE OF INFORMATION ❑ 7 PERMANE CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE s3 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> �iedP Cor�rh-ucf.o. <br /> ADDRESS NEZEST CROSS STREET ✓Bmfin*W D PARTNERSHIP D STATE AGED <br /> N. (1 Ct7 I [G`C OGa ICS ❑ WRgPATNN ❑ LOCAL-AGENCf ❑ R'OEIUL-AGEN(,7' <br /> ❑ MOMINVd ❑ couxnAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> L(9 CA <br /> TYPE OF BUSINESS: 2DISTRIBUTOR 4PROCESSOR ✓Rox N INDIAN EPA IDN Not TANKS <br /> ❑ ❑ SOTHFA RESERVATION <br /> or ❑ ATTHISSRE <br /> ❑ 1 GAS STATION ❑3 FARM ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) 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) 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 ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D 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 ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE 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 LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 111.❑ <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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> CO�UNTYY## JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE " <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMw <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CSUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 9 3� YES ❑ NO ❑ �'�CHECKN/ SURCHARGE AMOUNT FEE CODE RECEIPT N 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 INFORMATION4NLY- <br /> \, <br /> FOflM A(3-2-88) • � • <br /> �O u-u <br />