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STATE OF CALIFORNm WATER RESOURCES CONTROL BOARD <br /> A <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM 7" �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE aex`r <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 1� _�_ u_,fIvvE." C <br /> ADDRESS NEAREST CROSS STREET ✓ rdirbe D PARTNERSHIP D STATEAGEALY <br /> � rON D LOCK AA D FEDEPAL AGDO <br /> 'V i INDMWAL D QWM AGENCY <br /> CITY NAME STATE ZIP CODE <br /> SI E PHONE N,WITH AREA CODE <br /> CA � -3 6 O <br /> TYPE OF BUSINESS ❑ 2 DI RIBUTOR ❑ 4 PROCESSOR ✓Box 4INDIAN EPA ID It <br /> RESERVATION or Sol TANK'. <br /> E] GAS STATION 3 FApM ❑ 5 OTHER TRUST LANDS ❑ 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(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &A RESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> I/Box to ind.le D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCALAGENCYD FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME ATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE CO LETED) <br /> NAME CARE OF ADD INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL 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: 1. ❑ II. ❑ 111. ❑ <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 S JURISDICTION k AGENCY R FACILITY ID N S of TANKS N SITE <br /> DD Y DODD <br /> CURRENT LO AL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE <br /> i <br /> 17 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA ON CQDE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED <br /> (i� a YES NO 79 O <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY <br /> TH18 f0y(1 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 /> FORMA(3- ) V <br />