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STATE OF CALIFORNIA WATER RESOURCES CONTROL ,JARD �' '""'l'' <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM V �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'n,�r,ac`> <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F'A <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C�� ' N <br /> 07 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) w <br /> 4: <br /> FACILITY/$ITE NAME %'f'� CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓EmBNJnle ❑ P,ARTNUS1IP ❑ STATE.AGFNCY <br /> ❑ CAIPOROON ❑ LOCAL AGENCY ❑ EE➢EMLAGDO <br /> Gt OIJ NDMDUAL ❑ CWMAGBIC! <br /> CITY NAME STATE ZIPCOD <br /> 57 CA Fy�� SITE PHONE N.WITH AREA CODE <br /> %s <br /> TYPE OF BUSINESS: ❑p OISTRIBL1TOR ❑ d PROCESROfl ✓Box if INDIAN EPA ID N <br /> RESERVATION or K o1 TANK'# <br /> ❑ 1 GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE Jr 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 /> MAILING or STREET ADDRESS ✓Box to m,,,ate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓80x to IOEicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ 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)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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 k JURISDICTION k AGENCY R FACILITY ID# N of TANKS at SITE <br /> CURRENT LOCAL AGENCY pACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> ` / A V ' <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED / <br /> bl ���O yZ YES NO i/G <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <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(3-2,68) (� /✓^) (1./ <br /> DATA PROCESSING COPY <br /> VVV /VII d- <br />