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STATE OF CALIFORN1x WATER RESOURCES CONTROL BOARD <br /> FORM 'A': m <br /> � UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> 40- COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERM TLY LOSED SIT F-a <br /> ONE ITEM ❑2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE COODCO <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> u <br /> ADDRESS NEAREST CROSS STREET ✓Bab ❑ PNIT,4ER91P ❑ STATE AGENCY <br /> T,GN ❑ LOCkdGDO ❑ FEDEW AGENCY <br /> INDNIDWL ❑ CGHTYAGENM <br /> CITY NAME D/ STATE ZIPSITE PHONEN,WITH AREA CODE <br /> CA I <br /> TYPE OF BUSINESS'. ❑ 2,DjWr8UTOA ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID N Not TAWS <br /> RESERVATION or ❑ t / /�� AT THIS SITE D <br /> ❑ I GAS STATION 3 FARM ❑ 5 OTHER <br /> TRUST LANDS a 6 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,RRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> SX09 -Z- <br /> NIGHTS: NAME(LAST,FIRST) ~ PHONE N WITH AREA CODE I NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5 <br /> MAILING or STREET ADDRESS ✓BON to Indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ C TION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5 <br /> MAILING or STREET ADDRESS I/Box Ovate 13PARTNERSHIP ❑ STATE-AGENCY <br /> ElORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> rp NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP 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. IL ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCYIN FACILITY ID N N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LLOrATIONCODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAIN FILED DATE FILED <br /> YES NO PERMIT AMOU SURCHARGE AMOUNT FEE CODE RECEIPTN BY: n A <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 INFOR'MAA/T�JION ONLY. <br /> FORM A(3-2-88) <br /> �`' DATA PROCESSING COPY r— <br />