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STATE OF CALIFORNIS WATER RESOURCES CONTROROARD <br /> FORM `A': U ERGROUND STORAGE TANK PROGRAM 0 <br /> S 9 <br /> SITE F Y/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT RANGE OF INFORMATION o x. <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CL ❑ T PERMANENTLY CLOSED SITE <br /> OSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME r <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> I /r 1 <br /> NEAREST CROSS STREET ✓Byte irdraa ❑ PARTNDMIP ❑ STAIE AGENC! <br /> ❑ COMOPATmN ❑ LOCa-AGENCY ❑ FBXMLacB c <br /> CITY NAME ❑ INDMDIPL ❑ WINTiGSNC/ <br /> STATE ZIP CODE SITE PHONE q,WITH AREA CODE <br /> TYPE OF BUSINESS: CA❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> ❑ 1 GAS STATION ❑3 FARM ❑S OTHER RESEVATION TRUST LANDS or ❑ M of TANK'# <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE It WITH AREA CODE <br /> NIGHTS: NAME(( STFIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> (` v CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ^ ✓ x to indicate ❑ PA NERSHIP <br /> 13 STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAM ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> For+ NT L_�k STATE ZIP CODE PHONE k,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> ENAMEECARE OF ADDRESS INFORMATION <br /> REET ADDRESS ✓Box to indicate ❑ pgNERSHIP❑ CORPORATION ❑ LOL- STATE-AGENCY❑ INDIVIDUAL AGENCY ❑ FEDERAL-AGENCY❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,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: f. ❑ IL I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS T E AN OR <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY IDN <br /> N of TANKS at SITE <br /> CURRENT LOCAL AGEN/CY FACILITY IDN APPROVED BY NAME <br /> b O / PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPpOVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> 2 13 ` ^L� YES ❑ NO DATE FILED <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# ❑ <br /> BY: I <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERM61-0 PERMIT 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> CORM`(3-2-88) � Sti� \ 1 <br /> DATA PROCESSING COPY V <br /> \1\ <br />