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SEP eV QKa THF` <br /> STATE OF CALIFORN WATER RESOURCES CONTRBOARD <br /> FORM `A': ` <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION `p o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT F—I 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSUREaz 4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) � <br /> FACILITY/S NAME CARE OF ADDRESS INFORMATION <br /> t <br /> ADDRESS NEAREST CROSS STREET ✓ISM to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Rd chero Ke <br /> ,,pry El CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> C ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME � f STATE Z1P CODE SITE PHONE N,WITH AREA COOS <br /> -r{ fffss(�r� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR I�4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK'a <br /> I GAS STATION [:] 3 FARM 5 OTHER TRUST LANDS 1:1AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS, NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,RRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#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 ❑ FEOERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 1NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.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: L if. 7] 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> F <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> aa YES ❑ NO 1:1 <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# By: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(B), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-68) <br /> DATA PROCESSING COPY <br />