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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': �* � .. =' <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1�4 — N <br /> CD <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILI !SITE NAME: CARE OF ADDRESS INFORMATION <br /> iA .411 <br /> ADDRESS a <br /> f NEAREST CROSS STREET ✓Box laidc& ❑ PM7NEFSIIP ❑ STATEAGDO <br /> U ❑ WWORA ION ❑ LOCAL-AGDO ❑ FEf1EPo4-AGENCY <br /> ❑ FNOfNwk ❑ OWNTY-AGENCY <br /> i CITY N STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID it of TANK'a <br /> ❑ ❑ ❑ TRUSTVLANDS or ❑ <br /> I OA56TATION 3 FARM S OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br />' DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ' MAILING or STREET ADDRESS ✓Box to indicate _ ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPOAATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br />}p CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> j III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br />!I NAME CARE OF ADDRESS INFORMATION <br /> I ' <br /> I <br /> MAILING or STREET ADDRESS ✓Box to indicate Q PARTNERSHIP ❑ STATE-AGENCY <br />'I Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br />.� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE R <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 />) <br /> APPLICANT'S NAME(PRINTED S SIGNATURE) DATE <br /> j LOCAL AGENCY USE ONLY <br /> I <br /> j COUNTTYYj# JURISDICTION M AGENCY M FACILITY 10 M #of TANKS at SITE <br /> CUR NT LOCAL AOENCY FACILITY IDN APPROVED BY NAME Hp k WITH AREA CODE <br /> I (6 b, <br /> PERMIT NUMBER PERMIT.APPROVAL DATE P MIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO <br /> CHECK f PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON Y. <br /> FORM A(3-2-118) i <br /> — DATA PROCESSING COPY <br />