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STATE OF CALIFORNIA WATER RESOURCES CONTRO.OARD a <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �SITE ✓ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONCOMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 07, NBUA011_NTLY CLOSED SITE Na <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE I r <br /> 07 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NA CARE OF ADDRESS INFORMATION <br /> 64 � s gPr1T £ v v <br /> NEAREST CROSS STREET ✓Bm 1piMiWX ❑ PARINuBmw ❑ STATE AGENCY <br /> ADDRESS ( ❑ CORPDRATION 0 LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ CWNIY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE X,WITH AREA CODE <br /> CA s 6 <br /> EPA ID X <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box A IND( #of TANK's <br /> 5 OTHER RESERVATION or AT TT <br /> SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS' NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE X 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 0 FEDERAL-AGENCY <br /> D INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE X,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <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 X.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. ❑ 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 /> COUNTY M JURISDICTION Is AGENCY X FACILITY IDX #01 TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE X WITH AREA CODE <br /> 3Go'l'f <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDLNO [] <br /> DATE FILE <br /> YES � I <br /> CHECK# � PERMIT AMOUNT SURCHARGE AN FEE CODE REC <br /> v1 WgA <br /> I) 7/ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LE�(7)OR MORE TANK PERMIT FORM 'B'APPLICATIONS ESS THIS IS A CHANGE Of SITE INFORMATION ONLY. O <br /> ORM A(3-2-BS) \ <br /> \n /�\ DATA PROCESSING COPY \ <br />