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STATE OF CALIFORNI'P• WATER RESOURCES CONTROB•RD �~ <br /> e"` Jae <br /> W a <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F'a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -4 <br /> I. FACILITY/SITE INFORMATION &ADVIRESS- (MUST BE COMPLETED) N <br /> FACIA /SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓CORPORATIO Cl PARLOCAL AGENCY <br /> ❑ FEDTE ERAL ENCY <br /> AGENCY_ _�. O ❑ CORPORATION ❑ COUNTPGENCY ❑ FEDERAL PGENLY <br /> ClCI INDIVIDUAL CI Y AGENCY <br /> / STATE P CODE SITE PHONE#,WITH AREA CODE <br /> rf_' DM`1 CA S� <br /> TY NAME4 <br /> TYPE OFBUSINESS: ❑ ISTRIBUTOR ❑ 4PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> ESE <br /> E] 1 GASSTATION 3 FARM ❑ 5 OTHER TRUSTVATION LAND$o ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LA$T,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 Cl LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box in indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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: I. II. ❑ 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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID/t M of TANKS at SITE <br /> Z/ / 15V ld O d <br /> CURRENT LOCAL AGE Y A ILI 1/ ^ APPROVED BY NAME PHONE If AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT It SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D/ATE ILED <br /> 2'3. 23 a<^ YES NO b S` G <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT# BY: <br /> ass <br /> I 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 /> FORM A(3-2-00) <br /> DATA PROCESSING COPY 7 <br />