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l , <br /> STATE OF CALIFORNIO WAFER RESOURCES CONTROROARD <br /> We. •.SA <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAMI`� � <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACT ITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E]6 TEMPORARY SITE CLOSURE 2E —4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bo kale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> IO TION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> /�"l/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTO ❑4 PROC ✓Box if INDIAN EPA ID.# <br /> RESERVATION or #of TANK's <br /> ❑ R TRUST LANDS ❑ AT THIS SITE <br /> 1 GAS STATION E:]3 FARM THE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIR ) ) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OW ER INFORMATION'&ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 914 C <br /> MAILING or STREET ADDRESS ✓B indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> °.7 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ffd ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME ^ STATE ZIP CODE PHONE ITH AREA CODE <br /> (/t'/ � J <br /> 111. 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 /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE Al,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: I. ❑ if. 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 /> FPERMITNUMSER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> / 5 ❑ [ I I :D <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> ,,�3- c�'� YES ❑ NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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) <br /> % DATA PROCESSING COPY �` <br />