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STATE OF CALIFORNIR WATER RESOURCES CONTR�BOARD <br /> SEPI � M1 <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE I"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE - <br /> 1 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> A <br /> FACILITY/SITE y/yJE CARE OF ADDRESS INFORMATION <br /> ADDRESS �� , 1 NEAREST CROSS STREET ✓ ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ' I 1 0�1 CGRPORATION ❑ LOCAL ❑ FEDERAL AGENCY <br /> l 1 1 ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIPQODE SITE PHONE#,WITH ARE CODE <br /> CA a5 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID #SATION <br /> ❑ 1 GAS STATION ❑ 3FARM IEE TRUSTVLANDS or ❑ c-- AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LA5f-FtfI PHONE#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 odicaTe ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE ft.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME 14 CARE OF ADDRESS INFORMATION <br /> lj <br /> MAILING or STREET ADDRESS ✓Box la icdlcale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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 k Or of TANKS at SITE <br /> EZA 10101 - 101 (ol (o <br /> CURRENT LOCAL AGENCY FACILITY IO# APPROVED BY NAME >-301 PHONE#WITH AREA CODE <br /> So _T_7 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION E CEN TRACTj!_ SUPERVISOR-DISTRICT C�1DE BUSINESSPUN FILED NO ❑ DA_TE EILED <br /> CHECKM PERMIT AMOUNT SURCHARGE AMOUNT`d FEE CODE RECEIPT# BY: <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 <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />