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OF <br /> � <br /> STATE OF CALIFORNIP WATER RESOURCES CONTROPOARD <br /> F , <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•oa�`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT P�1 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <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 NAM CARE OF ADDRESS INFORMATION <br /> u ►-� el/ N <br /> ADDRESS NEAREST CR SS STRI E ✓BpMI01Toule ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 1 ❑ CORPGMTION ❑ LOGALAGENCY ❑ FEDEMLAGENGT 0 <br /> ❑ INDROUAL ❑ COUNTRAGENCY 0 <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR F❑ 44 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ ❑ I?a TRUST LANDS of ❑ a M� k of TANK'a <br /> 1 GAS STATION 3FARM OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> 0 YS NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Ld.I � <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH�AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE R WITH AREA CODE <br /> II. PROPERTY OWNE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e <br /> MAILING o,STREET AqQpESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU N ME� STAZIP CODE PHONE If WITH AREA CODE <br /> O <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME �n \ `I CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS ✓Box m Odicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ 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. ❑ II.w 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID k It of TANKS at SITE <br /> [ZE = = oZa 16 10 10002- <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE k WITH AREA CODE <br /> STO 12- <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# BUPERV OR•DISTRICT CODE BUSINESS PLAN FILEDDATE FILED <br /> YES [–] NO �– —O <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88)' • 0 1 S <br /> ' DATA PROCESSING COPY ' <br />