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STATE OF CALIFORNI1a• WATER RESOURCESCONTRCt-BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Of) <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) i✓ <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> L <br /> ADDRESS NEAREST CROSS STREET ✓Bw waacate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /� ❑ CORCIRATION ❑ LOCM-AGENCY ❑ FEDERAL AGENCY <br /> / c7 ❑ INDPHi Cl COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE S TE PHOVE X,WITH AREA CODE <br /> /,( CA ON48 ;21 <br /> TYPE OF SINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID X X of TANK's q <br /> 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYATION LANDS or ❑ AT THIS SITE LJ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(IAST. IRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> 1-101514-41 <br /> IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME ^ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS C' ✓bac to indicate ElPARTNERSHIP 11STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> / ❑ INDIVIDUAL ❑ COUNT'-AGENCY <br /> CISTATE ZIP CODE PHONE N,WITH AREA CODE <br /> TY NA E <br /> N - v- / <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> � Y <br /> MAILING or STREET ADDRESS ��✓Byy.x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 8 r', S W/CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N.WITH AREA CODE <br /> CIN E <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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY X JURISDICTION X AGENCY X FACILITY ID N X of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE*WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> OCATION CODE CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES <br /> * PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: <br /> ,IpHIS 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 /> JJF�RM A(3-2-RR) <br /> V glow DATA PROCESSING COPY V <br />