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STATE OF CALIFORNIA WATER RESOURCES CONTROLOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITEQCFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT I M 5 CHANGE OF INFORMATION ❑ 7 PERMA OSED 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/ E CARE OF ADDRESS INFORMATION <br /> ADDRESS��'l/•Jnv^,—K �'�( NEAREST CROSS STREET ✓BabiLub ❑ PARTNERSHIP ❑ STATE-AGBILY <br /> ❑ WRUPPTDN ❑ LDC&AGENLY ❑ FEDBlk AGDCY <br /> D MWOUA D Gahm-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: 2DISTRIBUTOR 4PROCESSOR -/Box it INDIAN EPA IDN Rof TANKS <br /> ❑ ❑ <br /> RESERVATION <br /> w r-1ATTHIS SITE <br /> ❑ I GAS STATION E]3 FARM ❑ 5 OTHER LA <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING w STREET ADDRESS ✓Boz to inoimle D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE C WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS ✓Box to lnd,cate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D 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: 1. ❑ If. ❑ HL❑ <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 N JURISDICTION M AGENCY N FACILITY ID# N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE A WITH AREA CODE <br /> E �3� <br /> PERMIT NUMBER PERMITAPPROVALDATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENBUSTRACTa SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI <br /> YES NO <br /> CHECKa PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-68) • • <br />