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e- �' - •w.. , 9 .. ♦ -T. , -.- - �+rn-1!V+r'�I}• — - _ .r :L.O.. !1 <br /> OF <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL ARD yE°•"" "�� <br /> WP: •:sx <br /> FORM `A': ym <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION A 10 <br /> R <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cy CIFORN'P <br /> MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> I` ONE ITEM INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ® —4 <br /> k ri7 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> F-� <br /> FACILITY/SITE NAME H CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br />` - �. ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> II . ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> f CITY NAME i STATE ZI ODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR RESERVATION xit INDIAN <br /> EPA ID # <br /> TAT <br /> f TANK'a <br /> 1 GAS STATION ❑3 FARM OTHER TRUST LANDS ❑ THIS SITE <br /> I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It 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 /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> r <br /> III. 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#,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. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> wol. Z111 :5D] [olinloll , <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROV BY AIP <br /> HONE#WITH AREA CODE <br /> r (J� <br /> PERMIT NUMBER. �� PERMIT APPROVAL DATE PERMIT E�R TON%AT <br /> r <br /> LOCATION CODE CENSUS <br /> ACTTT� SUP VISOR ❑ <br /> RICT CODE BUSINESS P NFILED DATE FILED <br /> 01 C23, Q/(Jj� YES NO [:] <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> i <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 /> I <br /> It <br />