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STATE OF CALIFORNIA WATER RESOURCES CONTROLGARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE c I'F "R �' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLYC SED511E <br /> ONE ITEM ❑ 2 INTERIM PERMIT [1] 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 O <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) w <br /> CD <br /> FACILITY/ NAME ^ CARE OF ADDRESS INFORMATION <br /> // CC <br /> ADDRESS NEAREST CROSS STREET ✓BmaadmW 0 PARTNERSHIP D STATE-AGBICN <br /> ❑ CORPORATION 0 LOCAL-AGwLY 0 FEDERAL-AGwIX <br /> IS/ ❑ INDMDG#- ❑ CDUNTAGENC(N <br /> CIN NAME STATE Z CODE SITE PHONE#,WITH AREA CODE <br /> CA Jra o <br /> NPEOFBUSINESS: 2DISTRIBIROR Lj4P SSOR ✓Boz iI INDIAN EPA ID # =BITE <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUSTYLANDS or ❑ ' <br /> AT TRIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATIO &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRES - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> D INDIVIDUAL D 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: 1. ❑ IL ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJU Y,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# #of TANKS at SITE <br /> m <br /> CURRENT LOCAL AGENCY FACILITY ID# LPERMIT <br /> PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATEPIRATION DATE <br /> LOCATION CODE C S TRACTJL SUPERVISOR-0IST PLAN FILED DATE F ED <br /> 3 (6�(J/` ES � NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMORECEIPTM IF I BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. r< <br /> ` <br /> FORM A�-BB) �a _ <br /> DATA PROCESSING COPY <br />