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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD x '" <br /> A . � I . <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "FOR <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE AME s CARE OF ADDRESS INFORMATION <br /> et <br /> ADDRESS V �� NEAREST CROSS STREET ✓Pw IPORADe 0 PWNU)Ck AGE ❑ STATTAGEMCY <br /> FEDEMAGE <br /> /V ❑ cowoR+nlx+ Cl uxuAGB+cr ❑ rFnexu-nc�na <br /> • 0 INDMI MAL 0 Courm AGENCY <br /> CITY NAME STATE CODE SITE PHONE N,WITH AREA CODE <br /> CA Sd5° d <br /> TYPE OF BUSINESS: PA ID p <br /> ❑ 2 DISTRIBUTOR ❑ d PROCESSOR Be.Box if INDIAN N of TANK'N <br /> RESERVATION or ❑ AT THIS SITE / <br /> ❑ 1 GAS STATION ❑3 FARM OTHER TRUST LANDS <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 /> MAILING or STREET ADDRESS ✓Box to mclicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - ( ST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Box to nM ate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STA 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 N TIFICATION AND BILLING: I. ❑ 11. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BE T OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N M of TANKS SI SITE " <br /> = = = dA a <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT N ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT ILS BUPERVISON-D j0T CODE BUSINESB PLAM F❑ILEO DATE FI�D\oJ^ 3 O1 YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTNBY/C\lZil <br /> TINS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> ORM A(3-2-88) <br /> I `/ <br />