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o x� <br /> STATE OF CALIFORNIA WATER RESOURCES CONTRA OARD <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAM ® �� <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> H,P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> [MARK ONLY ❑ I NEW PERMIT <br /> ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT <br /> ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACILITWSITE NAME <br /> A] Ia 1 ✓sP,I, m ❑ PARTNERSHIP Cl STATE AGENCY <br /> NEAREST CROSS STREET D CWDEPORATIGN D LOCAL-AGENCY D EEGERALAGENCY <br /> ADDRESS L <br /> MU1N SI ❑ womouAL ❑ COUNTY AGENCY <br /> N�,z7 STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> CITY NAME Tr CA <br /> ARA <br /> EPA ID p <br /> NRE OF BUSINESS: 2 DISTRIRU10fl ❑ <PRDCESSOR ✓Box if INDIAN _ Mol TANKY <br /> RESERVATION or AT THIS SITE <br /> ❑ t GAS STATION ❑ 3 EARN ❑ 5 OTRER TRUST LANDS El <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST FIRST) PHONE N WITH AREA CODE DAYS: NAME(IST,FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST ADDRESS <br /> BECOMPLLETED) <br /> ARE OF NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> STATE ZIP CODE PHONE A.WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box tc indicate D PARTNERSHIP Cl STATE AGENCY <br /> ❑ CORPORATION D LOCAL AGENCY D FEDERALAGENCY <br /> D INDIVIDUAL Cl COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N.WITH AREA CODE <br /> CITY NAME <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. ❑ it. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> �I COOUTNTT/Y M II JURISDICTION K AGENCY M FACILITY IDM W of TANKS M SITE <br /> 1-- -+--I--� �� _ <br /> CURRENT LOCAL/A�O�ENCY FACILITY ID k <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT EXPIRATION DATE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> DATE ` <br /> r\ LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED FILED/ J <br /> YES ❑ NO ❑ <br /> CHEC N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERYIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> \'\� FORM A(3-2-881 <br /> V <br />