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STATE OF CA! LIFORNi; WATER RESOURCES CONTR;W�BOARD <br /> FORM A: <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION IBJ7 PERMANENTLY CLOSEDISITE. <br /> ONE ITEM -.:? <br /> 02 INTERIM PERMIT 0 4 AMENDED PERMIT E]6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BEICOMPLETEDY <br /> FACtLITY/SITE DAME6ARE OF ADDRESS INFORMATION <br /> 'TN <br /> L <br /> CORpC'T'O' 0 L A <br /> C3 COU <br /> ADDRESS NEAREST CROSS STREET ✓BOX10irloicalp El PARTNERSHR Cl STATE-AGENCY <br /> PORATION 0 LOCAL-AGENCY [I FEDERAL-AGENCY <br /> INDIVIDUAL Cl COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> I A CA <br /> TYPE OF BUSINESS: ❑ 2 DSTRIBLITOR El 4 PROCESSOR ✓Box if INDIAN EPA ID N #of TANK73 <br /> 1 GAS STATION 3.'FARME-5VA <br /> - ANDSiD <br /> TRUST LANDS RESERTION or AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) k EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE DAYS: NAME(LAST,FIRST) .1 PHONE#WITH AREA CODE <br /> NIGHTS' NAME ST,FIRST) PHONE#WITH AREA CODE NIGHTS', NAME(LAST,FIRST) PHONE q WITH AREA CODE <br /> [I. PROPERTY OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS7 V Box to indicate E3 PARTNERSHIP El STATE-AGENCY <br /> Cl,.CoRPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> '1'&� T El INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) <br /> NAME 'CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Box to indicate C3 PARTNERSHIP Q. STATE-AGENCY <br /> 13 conPORATION 0 LOCAL-AGENCY FEDERAL-AGENCY <br /> . <br /> 0-INDIVIDUAL 0 GOUNry-AGENCY <br /> CITY NAME STATE 71PCODE PHONE#.WITH AREA CODE_ <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS li <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. <br /> L <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OFPERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAVE(PRINTED&SIGNATURE) li DATE <br /> it y <br /> LOCAL AGENCY USE ONLY i� <br /> q <br /> i FACILITY 10# Ill of TANKS at SITE <br /> COUNTY# 1JUIRISIDICTION# AGENCY# j <br /> F-71 <br /> CURRENT LOCAL AGENCY.,FACILITY IDM APPROVED BY NAME PHONE 4 WITH AREA CODE <br /> 'jA <br /> IiF <br /> PERMIT NUMBER PERMIT APPROVAL DATE ij PERMIT EXPIRATION DATE <br /> ii <br /> LOCATION CODE CENSUS TRACT 0 SUPERVISOR-DISTRICT:CODE BUSINESS PLAN FILED DATE FILED <br /> YES [j NOE] <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT CODE RECEIPT.# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 113"APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> L <br /> FORM A(3-2-SS) it <br /> FILE COPY <br />