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STATE OF CALIFORNIP WATER RESOURCES CONTROL <br /> OL BOARD <br /> FORM `A': <br /> UNbIERGROUND STORAGE TANK PROGRAMA <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM Q INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ' 2 <br /> Cf. <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> �---�T <br /> ADDRESS NEAREST CROSS STREET ✓Box toindicatE ❑ PARTNERSHIP ❑ STATF-AGENCY <br /> (� y D ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> �I I i �/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: F—] p DISTRIBUTOR ❑ 4 PRCCESSOR ✓Box if INDIAN EPA ID # R o1 TANK's <br /> ❑ 1 GAS STATION [:] 3 FARM ❑ 5 OTHER TRUSTvLANDS cATION r ❑ 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(LAST,FIRST) PHONE#WITH AREA CODE NIGHTSNAME(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 ❑ LCCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION 81 ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION E] 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. ❑ if. ❑ 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 /> =COUNTY# JURISDICTION# AGENCY# FACILITY ID# #Lof TANKS at SITE <br /> ILL] d <br /> CURRENT LOCAL AGENCY FACI TV ID O APPROVED BY NAME PHONE k WITH AREA CODE <br /> PERMIT NUMBER If PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 0 BY � <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLE THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 0 DATA PROCESSING COPY <br />