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STATE OF CALIFORNIN WATER RESOURCES CONTROBOARD <br /> FORM `A': : <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `"��ea R.' <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT Ej 5 CHANGE OF INFORMATION LJO ' PPERMANENTL LOSEDSITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 10 <br /> FACILITY/SITE N CARE OF ADDRESS INFORMATION <br /> si <br /> ADDRESS N <br /> NEAREST CROSS STREET ✓NOrlPORATIO 0 LOCAL AGENCY <br /> Cl FEDERAAGEN <br /> ❑ <br /> CORPORATION 0 COUNTY <br /> YAGEN ❑ FEDERAL <br /> ❑ <br /> INDIVIDUAL ❑ WdN1V-AGENCY �yy <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE v' <br /> CA <br /> TYPEOFBUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ ❑ ❑ TRUSTYLANDSATION o ❑ ATTNISSITE <br /> 1 GAS STATION 3 FARM 5 OTHER <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(I-AST FIRSTI ^ 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 -./Be.to indicate 0 PARTNERSHIP Cl STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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: 1. ❑ I. ❑ 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 /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> m by ' UaC) 101 <br /> CURRENT LOCAL A NCY FACILITYIDa APPROVED BY NAME PHONE It WITH AREA CODE <br /> J <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES [:] NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> 1 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 /> \\ FORMA(3-2-88) <br /> `4� is DATA PROCESSING COPY 0 <br />