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STATE OF CALIFORNIA" WATER RESOURCESCONTROL`140ARD 5`x <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -® z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> N <br /> FACT SITE NAME ✓ CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ igirale 0 PARINE6SHIP 0 STATE AGENCY <br /> Id0M`F0N 0 LOCAL AGENCY 0 ROEWAGENCY <br /> INDNDUAL 0 CWNIY AGENCY <br /> CITY NA E STATE ZIP ODE SITE PHONE N.WITH AREA CODE <br /> lv CA <br /> TYPE OF BUSINESS, ❑I p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID N <br /> RESE❑ lU.� ❑ TRUSTVLANDS ATION�r ❑ MoTHIS SITE / <br /> 7 GAS STATION FARM 5 OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE Al WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or E ADD ✓Bgyi6indoate 0 PARTNERSHIP 0 STATE-AGENCY SII <br /> ORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STAT ZIP ODE PHONE M.WITH AREA CODE <br /> 53 <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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. ER-tE—] 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 R JURISDICTION N AGENCY X FACILITY ID N N of TANKS RI SITE <br /> um I I I/Vv <br /> CURRENTLOCALA NCy{ACILI IDN/ J APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER Tv�l L PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOC AT CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PPLAN FILED NO ❑ OAT F, <br /> D <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N (/a BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 1 FORMA(3-2-SB) <br /> DATA PROCESSING COPY ,II <br />