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WATER RESOURCES CONTRSOARD <br /> STATE OF CALIFORN _ o z <br /> FORM `A" UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE T PERMANENTLY CLOSED SITE <br /> 1 NEW PERMIT <br /> El 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION rV <br /> MARK ONLY ❑ El6 TEMPORARY SITE CLOSURE CLOONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT <br /> MUST BE COMPLETED) <br /> I. FACILITY/SITE INFORMATION III ADDRESS — ( DARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME <br /> / NEAREST CROSS STR ET ✓D�IoiMiwle Cl PARTNERSHIP O STA AGENCY <br /> / Cl wRPO T10N ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> ADDRESS ' L L/ Cl INDIVIDUAL 0 CAONTY AGENCY <br /> `7✓ t $TATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CITY N CA <br /> EPA IDN poi TANK's <br /> TYPE OF BUSINESS: F-12 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN AT THIS SITE <br /> RESERVATION or ❑ <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> DAYS: NAME(LAST.FIRST) PHONEN WITH AREA CODE <br /> PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> ❑ STATE-AGENCY <br /> ✓Box Lo RATIION 0 LOCAL-AGEN <br /> Clte PARTNERSHIP <br /> MAILING or STREET ADDRESS ❑ CORPORATICY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE <br /> ZIP CODE PHONE N,WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME a0 LOCAL-AGEN <br /> ❑ STATE-AGENCY <br /> ✓Box io intlATI 0 PARTNERSHIP <br /> MAILING or STREET ADDRESS 0 CORPORATION 0 COUNTY AGENCY G FEDERAL-AGENCY <br /> ❑ INDIVIDUAL PHONEN WITH AREA CODE <br /> STATE ZIP 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. El III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNODATE LEDGE, IS TRUEE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY FACILITY ID p p of TANKS at SITE <br /> JURISDICTION p AGENCY p <br /> COUN7Yp ` <br /> mPHONE N WITH AREA CODE <br /> APPROVED BY NAME <br /> CURRENT LOCAL AGENCY FACILITY ID N <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> DATE FILED <br /> LOCATION CODE CENSUSTRA N BUSINESS PLAN FILED <br /> SUPERVISOR-DISTRICT CODE YES El NO <br /> SURCHARGE AMOUNT FEE CODE <br /> pECEIPTN BY: <br /> CHECK N PERMIT AMOUNT <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST MORE TANK PERMIT FORM `Br APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ON Y. <br /> FORM A(3-2-83) <br /> DATA PROCESSING COPY <br />