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STATE OF CALIFORNIN WATER RESOURCES CON00BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACY FACILITY/SITE `^"F.A <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE [� <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> &/ ,,, 0/77S <br /> ADDRESS NEAREST CROSS STREET ✓Rm to mum 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL AGENCY 0 FEDEPALAGENLY <br /> / ig 5 Cl INUMDUAL 0 COUNTY.AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE If,WITH AREA CODE <br /> C�nJ CA 5205— <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID n <br /> ❑ If of TANK's <br /> T GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION <br /> Or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE At WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It 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,,d,cate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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. ❑ 11. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION R AGENCY N FACILITY ID N M of TANKS at SITE <br /> Ell I <br /> CURRENT LOCAL AGENCY FACILITY IO M APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> -IV44/40 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL <br /> ��. D�.J ZYES NO ( <br /> CHI PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> C <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(SI, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> 1 FORMA(3-2-5 <br />