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STATE OF CALIFORNIA WATER RESOURCES CONTROL OARDr-o <br /> M1 SE P`....rt <br /> � .'l�F <br /> { f <br /> CORM A : UNDERGROUND STORAGE TANK PROGRAM " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <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 Z <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W <br /> FACILITY/SITE NA CARE OF ADDRESS INFORMATION <br /> J <br /> ADDRESS NEAREST CROSS STREET ✓BorloiMicat. ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ..{� ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> 1 ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME // � � STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> (�Xe CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # _ <br /> ❑ 1 GAS STATION ❑3 FARM ❑ S OTHER TRUSTYU+NDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE N 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 od,cate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Gox to in0icate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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. ❑ If.❑ <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 N If of TANKS at SITE <br /> = = = I I h 1,316d <br /> CURRENT LOCAL AGENCY 7FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> V <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTMSUPERVISOTRICT CODE BUSINES;P SN FILED NO <br /> 1:1DATE FILED <br /> 2�9D <br /> 2.6 <br /> CHECK# 2 23 Oen PERMIT AMOUNT SURCHARRGE AMOUNT FEE CODE RECEIPT M BY: <br /> �.1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST 110R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON .� <br /> v_FORM A(3-2-88) <br /> DATA PROCESSING COPY 0 <br />