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STATE OF CALIFORA WATER RESOURCES CONT BOARD <br /> s <br /> FORM 'A': " <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION } <br /> I� <br /> COMPLETE THIS FORM FOR EACH FA ILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P SED SITE )-.1 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 �J <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) to <br /> FACILITY/SITE NA CARE OF ADDRESS INFORMATION cn <br /> ADDRESS t <br /> ENEARESTCHOSSTREET ✓Bor.Iovylxd@ D PARTNERSHIP D STATE AGENCY <br /> D CORPORATION D LOCAL AGENCY D HWHIAL AGENCY <br /> ❑ INOIVIWAL D COUNTY'-AGENCY <br /> CITY NAME _ ZIP CODE SITE PHONE 4,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax it INDIAN EPA ID N <br /> RESERVATION or N of <br /> I GAS STATION <br /> ❑ ❑ 3 FARM 5 OTHER❑ TRUST LANDS ❑ AT THHISIS SITE U <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 N 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 ✓Box to inocate <br /> ID PARTNERSHIP STATEAGENCY❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> D INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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 in 11 PARTNERSHIP ❑ STATE-AGENCY <br /> E] CORPORATION D LOCAL AGENCY D FEDERAL AGENCY <br /> Cl INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. ❑ if. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION Ill AGENCY M FACILITY ID N A of TANKS al SITE <br /> / T7a <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> 1''Y� PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACTF SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> DATE FILED <br /> \L YES NO <br /> Y CHIPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 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 INFOR ATION ONLY. <br /> DATA PROCESSING COPY <br />