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STATE OF CALIFORNI10 WATER RESOURCES CONTROL OARD <br /> `A': _� t <br /> FORM 0 <br /> UNDERGROUND STORAGE TANK PROGRAM /moo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Q <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 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �+ <br /> J <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE AME <br /> ADDRESS NEAREST CROSS STREET ✓Ro0 x to inairale 0 PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION LOCALAGENCY 0 FEDERALAGENCY <br /> --T/ "—J ❑ INDIVIDUAL ❑ CGUDY AGENCY <br /> L STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CITY NAME <br /> L ti CA <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID n #of TANK's <br /> RESERVATION or AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE If WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE 9 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> ✓Box to intlicate 0 PARTNERSHIP 0 STATEAGENCY <br /> MAILING or STREET ADDRESS <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL AGENCY <br /> Cl INDIVIDUAL [I COUNTYAGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <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. E] II. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION N AGENCY# FACILITY ID# QARE.A.0 <br /> atSITE <br /> 9 l <br /> CURRENT LOCAL AGENCY FACILITY ID M <br /> APPROVED BY NAME CODE <br /> / PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PERMIT NUMBER ,Z ' p[LOCATION CODE CENSUSTRACTM SUPERVISOR-DISTRICT CODE BUSINES YESN FILED NGCHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT NiY/THIS FORM MUST BE ACCOMPANIED BY AT LEAST(i)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNL�HIS IS A CHANGE ATION ONLY. <br /> FORM A(3-2-88) • <br /> \ DATA PROCESSING COPY \ <br />