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P <br />TATE OF CALIFORNI WATER RESOURCES CONTROOARD P`° "' "F <br />S <br />FORM `A': <br />UNDERGROUND STORAGE TANK PROGRAM <br />SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Y - ° 1.10 <br />COMPLETE THIS FORM FOR EACH FAPLITY/SITE "`lk� l" <br />I-1MARK ONLY 1 NEW PERMIT F—]3 RENEWAL PERMIT 2r5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />FACILITY/SIT NAME <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />ADDRESS <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />NEAREST CROSS STREET <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />/ <br />STATE <br />ZIP CODE <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />CENSUS TRACT # <br />0 <br />Cl INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE #, WITH AREA CODE <br />RECEIPT If <br />CA <br />TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR <br />F-14 PROCESSOR <br />✓ Box if INDIAN <br />EPA ID # <br /># of TANK's <br />❑ 1 GAS STATION ❑ 3 FARM <br />❑ 5 OTHER <br />RESERATION <br />TRUST LANDS or ❑ <br />AT THIS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE It WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br /># of TANKS at SITE <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE #, WITH AREA CODE <br />III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br /># of TANKS at SITE <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE #, 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: 1. ❑ 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 />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (t) OR MORE TANK PERMIT FORM `B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION 041,1,, <br />FORM A (3-2-88) <br />DATA PROCESSING COPY <br />JURISDICTION # <br />AGENCY # <br />FACILITY ID # <br />I / ' � <br /># of TANKS at SITE <br />AGENCY FACILITY ID <br />/� <br />APPROVED BY NAME PHONE # WITH AREA CODE <br />FERN <br />PERMIT APPROVAL DATE <br />RMIT EXPIRATION DATE <br />CENSUS TRACT # <br />0 <br />SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED <br />YES NO <br />DATE FILED <br />PERMIT AMOUNT <br />SURCHARGE AMOU T <br />FEE CODE <br />RECEIPT If <br />Y: <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (t) OR MORE TANK PERMIT FORM `B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION 041,1,, <br />FORM A (3-2-88) <br />DATA PROCESSING COPY <br />