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STATE OF CALIFORA WATER RESOURCES CONT. _L BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ila <br /> COMPLETE THIS FORM FOR EACH FA LITY/SITE Cy(iOpN P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT li2<CHANGE OF INFORMATION ❑ 7 PERMANENILYjCLOSED 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 NA E CARE OF ADDRESS INFORMATION <br /> 7 <br /> ADDRESS NEAREST CROS STREET I/Box to indicate ❑ PARTNERSHIP Cl STATE AGENCY <br /> t El I/ <br /> ElLOCAL-AGENCY C3 FEDERAL AGENCY <br /> -� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHON p,WITH AREA COD <br /> CA <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PRO ESSOR ✓Bax it INDIAN EPA ID a <br /> TRUST LANDS or ❑ M of TANK'! <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS, NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE rr WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADD SS INFORMATION <br /> L2,5 D <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAM-) <br /> M- STATE ZIP CODE PHONE N,WITH AREA CODE <br /> J( C <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 <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE ti,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDREU 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 /> [PERR <br /> JURISDICTION M AGENCY M FACILITY IDM M of TANKS at SITE <br /> AGENCY FACILITY ID APPROVED BY NAME/! PHONE!t WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NOPERMIT AMOUNT SURCHARGE AMOUNT____JFEE CODE RECEIPT M 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 ONLY. (� <br /> FORM A(3-2-88) LIU <br />