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STATE OF CALIFORNIkr' WATER RESOURCES CONTROEtOARD <br /> a <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m I C) <br /> COMPLETE THIS FORM FOR EACY 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 —4 rl <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) pp <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESSNEAREST CROSS STREET ✓BwlokAr&e Cl PARTNERSHIP El STATE-AGENCY <br /> 2 / 0 CORP TON 0 LOCAL-AGENCY 0 FEDGWAGENCI <br /> (� ❑ INOMWAL 0 couo4cENcY <br /> CITY NAME STATE ZIP CODE SITE,PHONE N,WITH AREA CODE <br /> Q N CA <br /> TYPE OF BUSINESS. ISTRIBUTOR F-1d PROCESSOR ✓Box if INDIAN EPA ID 0 #of TANKS <br /> ❑ 1 GASSTATION 3 FARM ❑ 5 OTHEfl TTRUSTVLANDS ATION o 1:1AT 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 & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e as <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 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM P ! CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box W aTicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> I <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. it. ❑ 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 /> aaaaaaaaaa <br /> COUNTY# JURISDICTION R AGENCY# FACILITY ID# If of TANKS at SITE <br /> an I I I q I / o <br /> CURRENT LOCAL AGEN'C FACCIILITY 1 #1 APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER i//{// (TJ�I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED <br /> YES NO <br /> I^�/I CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <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 INFORMATION ONLY <br /> FORM A(3-2-SS) <br /> DATA PROCESSING COPY <br />