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STATE OF CALIFORNIP WATER RESOURCES CONTRCROARD <br /> Y A <br /> FORM 'A': " m <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F LITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE 6G <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> "OV <br /> ADDRESS NEAREST CROSS STREET ✓Bw WMOO ❑ PARTNERSHIP ❑ STATE AGENCY <br /> Cl 5" M/�ih ❑ INDYIGAL� 11COUNAGENCY <br /> FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE <br /> CA 9 C-I3 O <br /> TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓BOx if INDIAN EPA ID N <br /> RESERVATION or11 - Not TANKS / <br /> ❑ I GAS STATION E] 3 FARM ❑ 5 OTHER TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(IAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME q CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRE ✓Box to indicate PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE FPHONE Jr.WITH CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) moi/ <br /> NAME Z CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADORIEU SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ Ill.❑ <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION R AGENCY B FACILITY IDR N of TANKS N SITE <br /> � = a / <br /> CURRENT LOCAL AGENCY FACILITY IDR / APPROVED BY NAME PHONE R WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION C DE CENSUS TRACT M SUPERVISOR-DISTFUCT OOE BUSINESS PLAN FILED DATE FILED <br /> � <br /> (a/ ��� 5 ❑ <br /> YES NO [:] /2 <br /> CHECK R PERMIT AMOUNT SURCHARGE AMO FEE CODE RECEIPT It BY: <br /> 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMR FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> RM A(3-2-88) 0 <br /> 0 <br /> L <br />