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STATE OF CALIFORNI <br /> FORM `A': WATER REsouRces <br /> CONTROL BOARD <br /> W: <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °+�,_�o �e <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION H7' <br /> ONE ITEM 7 PERMANENTLY CLOSED SITE <br /> ❑ 21NTERIM PERMIT ❑q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1150 <br /> •Q <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FADDREtSS <br /> 'A <br /> CARE OF ADDRESS INFORMATION <br /> Q <br /> NEAREST CROSS STREET ✓BOAIP ird(c ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 3 / LU C ❑ GRPGAATON ❑ LGGL AGEN ❑ FEUEA bAGEN❑ PICNIC AL ❑ COUNTY AGENCY <br /> STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> F BUSINESS ❑ p DISTRIBUTOR-1/-❑4 PROCESSOR ✓gox it INDIAN EPA D pRESA <br /> ❑ I GAS STATION ❑3 FARM ❑5 OTHER TRURESSTVLAT <br /> ANDS o ❑ #of 7ANK'a <br /> A7 THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE ft WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓80x to intlicate ❑ PARTNERSHIP <br /> 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ STATE-AGENCY <br /> TATEFEDER-GENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY AGENCY <br /> CITY NAME STATE ZIP CODE <br /> PHONE p.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. ❑ it. ❑ 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&SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# <br /> D #of TANKS at SITE <br /> EEIHZ <br /> CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME <br /> Me <br /> �J PHONE a WITH AREA CODE <br /> PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> DATE FILED <br /> CHECK# PERMIT AMOUNT SURCHARG AMOUNT YES /Z �1 <br /> FEE CODE RECEIPTIf 3# By. V <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 ONL <br /> FORM A IS 2-8 <br /> DATA PROCESSING COPY ,� <br />