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hF'�u��e •rhf <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �� <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM _ �" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWALPERMIT 5 CHANGE OF INFORMATION El 7 PERMANENTLY CLO E O <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAME � ' ` ,/Y 1� r/ CARE OF ADDRESS INFORMATION <br /> , ❑ STATEADDRESS NEAREST{BOSS STREET 0 FARTNE <br /> Lf v ❑ IwN O LOCAL ❑ FxuL AGENCY <br /> ❑ INDMDIN / ❑ COUNTY- <br /> AGENCY <br /> CITY NAME STATE ZIP CODESITE PHONE I.WITH AREA CODE39� <br /> TYPE OF BUSINESS: p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box A INDIANIF EPA ID N a/ <br /> Mol TANMN <br /> RESERVATION or ° <br /> ❑ I GAS STATION ,3 FARM El OTHER TRUST LANDS ❑ i AT THIS SITE / <br /> EMERGENCY CONTA67,PERSON(PRIMARY) EM GENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) -.� PHONE N WITH AREA CODE YS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LRST,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 indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZW CODE PHONE N,WITH AREA CODE <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 Cl COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE N.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. I ❑ III,❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE,'JS TRUk AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION C E CENSUS TRAC/0 SUPERVIS2OR-DIS ICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AN1UNT FEE CODE RECEIPTN <br /> V ' <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY{ _ <br /> FORMA(az-Be( , <br /> �� �—' DATA PROCESSING COPY \ <br />