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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> Ij . <br /> FORM `A'. <br /> k�. . UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ' COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑b TEMIPORARY SITE CLOSURE' O Z ' <br /> EG <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION <br /> (Soullc.1Li <br /> i, N <br /> ADDRESS I NEAREST CROSS'STREET lo'nOc'ete ❑ PARTNERSHIP ❑ STATE-AGENT a) <br /> ❑ CORPORATION ❑ LOX-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE W <br /> CA 455 <br /> ! TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA!D N ";' <br /> RESERVATION or k of TANK'# <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUST LANDS ❑ At THIS SITE <br /> 4 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> f. <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(Lj'AST,FIRST) - PHONE#WITH AREA CODE <br /> I! <br /> I <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> f I <br /> ' MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY [ <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY , <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> I� <br /> { III. TANK OWNER INFORMATION &ADDRESS -- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ' MAILING or STREET ADDRESS ✓BOX to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ fEDERAL-AGENCY r <br /> ❑ INDIVIDUAL - ❑ COUNTY-AGENCY /- <br /> I CITY NAME STATES 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: L ❑ II. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> ;. t <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS st SITE <br /> EH I I E] I I I I I oo ' I o lild Eo lo I ol /I <br /> CURRENT LOCAL AGENCY FACILITY Ip# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT.APPROVAL DATE PERIIIt1T EXPIRATION DATE <br /> LOCATION CODE GfNSU8 TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORA MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M `B'APPLICATION(S),-UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ' <br /> FORM A(3-2-BS) <br /> DAA tROCESSING COPY <br />