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STATE OF CALIFORNO WATER RESOURCES CONTABOARD z` �F. <br /> FORM 'A': s <br /> UNDERGROUND STORAGE TANK PROGRAM ' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> COMPLETE THIS FORM FOR EACH FA ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 —4 <br /> w <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ,n <br /> ADDRESS p NEAREST CROSS STREET ✓Rp,bNOW Cl PARTNERSHIP ❑ STATE AGENCY <br /> + tN ❑ CORPORATION 11LXkAGBCY Cl FEDERALAGENCY <br /> CITY NAME ❑ INDNIDUAL 0 COUNTY AGENCY <br /> 5+�1 STATE ZIIC��O SITE PHONE k,WITH AREA CODE <br /> C a nom <br /> TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓ <br /> ❑ Box It INDIAN EPA ID p <br /> ❑ I GAS STATION ❑3 FARM ❑ 5OTHER RESERVATION or #of TANK'# O� <br /> TRUST LANDS ❑ 1'LO 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) PHONE k WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTYAGENCYCITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRES INFORMATION <br /> me �' cc r c I T L- e � <br /> MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 13COUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE k,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. ❑ III. <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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> I I q I o 010 1 O 0 <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> M& P, yo APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DI RIOT CODE BUSINESS PUN FILED DAT"llyl <br /> OYES NOCMECKM PERMIT AMOUNT SURCHARGE MOUNT FEE CODE RECEIPTM <br /> Miss <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 ONL <br /> FORM A(3-2-8B) <br /> \^} • DATA PROCESSING COPY <br />