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L�IFORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 1 COMPLETE THIS FORM FOR EACH FACILITY/SITErV <br /> MARK ONLY F__] 1 NEWPERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION Y"'Y 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE "s' <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILINBI�AMECARE OF ADDRESS INFORMATION <br /> A S <br /> L ADDRESS NEAREST CROSS STREET ✓de.t udcxk ❑ PARiNEA ❑ STATEAGOO <br /> C /�/�,, Q /� ❑ O7�OMTKM ❑ LOGLAGBILY ❑ FEDUK-AGENCY <br /> ash 1 �s 'a/on .9 .n0`� ❑ INMVNWL ❑ WUO AGENC( <br /> CIT'NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> ytiaciqLG <br /> r.l CA / <br /> TYPE OF BUSINESS: ❑ 2 IBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N R of TANK's <br /> RESERVATION or AT THIS SITE <br /> III ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ ' <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> `, DAYS: NAME(LAST FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME( AB ,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> -i II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> LMAILING or STREET ADDRESS -V Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 1 i ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> i I III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> �I NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORTION 11FEDERAL-AGENCY <br /> 1:3 NDIIVIDLEl COUNTY-AGENCY <br /> i1 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 ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ I. ❑ 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 /> COJU�NTTYY# JURISDICTION# AGENCY## I FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> Li <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE <br /> Alp <br /> 3 Z YES NO ; <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BV: <br /> !!! - THIS FORM MUST BE ACCO�p'7DANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM\3-2 <br /> �91 .r DATA PROCESSING COPY -� <br />