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STATE OF CALIFORNI WATER RESOURCES CONTROBOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ry „ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION '/ 1r�� <br /> 1 COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I 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 I %, <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INI'UHMATION <br /> ADDRESS NEAREST CROSS STREET ✓6y YHYkII! 0 PAAINEIEW 0 STATE AGENCY <br /> r 0 UYPOIRIUN 0 LOCA AGENCY 0 HIERALAGENCY <br /> . 0 INOYLWI 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑/PROCESSOR ✓Box if INDIAN EPA ID Y Y of TANKY <br /> ❑ I GAS STATION ❑ 3 FARM ❑5 OTHER TRUST LANDS VATION m ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME _ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Inoicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> .A <br /> MAILING or STREET ADDRESS ✓Box bind,:ale 0 PARTNERSHIP 0 STATE-AGENCY <br /> - F I�; �, f ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AflEA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRLBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. it. ❑ 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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYFI JURISDICTION Y AGENCY Y FACILITY ID Y No ITANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE Y WITH AREA CODE <br /> I ri <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION <br /> BE CENSUB TRACT Y BUPERV180R-DISTRICT LODE BUSINE88 PLAN FILED DATE FILED <br /> y YES NO <br /> CHELKI PERMIT AMOUNT WRCHAROE AMOUNT FEE CODERECEIPTN BY: _ !� <br /> \ <br /> A ` THIS FORM MUST BE ACCOMPANIED BY AT LEASJWR MORE TANK PERMIT FORM 'S'APPLICATION($), IINI ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> W OHM A(3.2-88) <br /> -�� <br />