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STATE OF CALIFORNI/ol WATER RESOURCES CONTRO 'BOARD <br /> .a <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Y� r no � <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° h <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE �glfF0RW <br /> MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 <br /> I, FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FAC1L TY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS ii NEAREST CROSS STREET y/RostoNicate [:1 PARTNERSHIP ElSTATE-AGENCY <br /> ❑ GORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> I'I ❑ INDIVIDUAL ❑ MUNN-AGENCY <br /> CITY NAM STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE O 51NE55: ❑ 2 DISTRIBUTOR F__] 4 PROCESSOR ✓f3ax if INDIAN EPA ID a _ N of TANK's <br /> 1 GAS STATION 3 FARM <br /> El OTHER TRUST LANDS�r 1:1AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING of STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-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 Cl STATE-AGENCY <br /> ❑ CORPOHATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME r 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: 1. ❑ II. ❑ 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OR PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS of SITE <br /> Lj I I r I -) <br /> I ED1 Li CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE k WITH AREA CODE <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOILI <br /> CATION CODE CENSUS TRAC k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILE <br /> 1 r_ -3 �- j YES NO � �/ <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY: —4-- — <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 ONLY, <br /> 5 <br /> FORM A{3-2-88) <br /> DATA PROCESSING COPY <br />