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PTATE OF CALIFO►RNI WATER RESOURCES CONTROL BOARD <br /> FORM `A': xT A,;� <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> .11 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Cp <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) Cp <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS � / NEAREST CROSS STREET ✓Box lPORA I Cl PARTNELOCAL-ASHRGENCY <br /> ❑ $TATE-GENCY <br /> L-AOEN <br /> ❑ CORPORATION ❑ LOCAL�AGfNCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE IAITE PH NE#,WITH AREA CODE <br /> cA S3 �' - 5 <br /> TYPE OF SINESS, ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR7R'ME-R-111, <br /> i(INDIAN EPA ID # #of TANK'® <br /> 1 GAS STATION ❑ 3 FARM ❑ <br /> 5 OTHER ANDS 1 N or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST,FIRST) PHONE#WITH AREA COLE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> -/Box to indicate ClPARTNERSHIP ❑ STATE-AGENCY <br /> f!�' ❑ CORPORATION 13LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME `� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl 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. ❑ Ilf. ❑ <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 /> [LOCATION <br /> OUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> I 1 1:1 1 1 11 r I I I I I i I I T I j <br /> EHT`OL AGENCY I ID# APPROVED BY NAME, PHONE N WITH AREA CODE <br /> T NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CODE C€NSUS TRACT# SUPERVISOR-DISTRICTCODE BUSINESS PLAN FILED DATE FILED <br /> -IN YES NO <br /> ❑ � f <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# T: <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. <br /> ECRM A(3-2-88) <br /> DATA PROCESSING COPY <br />