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STATE OF CALIFORNIA'` WATER RESOURCES CONTROL BVARD <br /> °m Z. <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM _ o <br /> SITE � ypACILITY/SITE, INFORMATION and/or PERMIT APPLICAT <br /> C..! COMPLETE THIS FORM FOR EACH F ITY/SITE ""�� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P NR CL D SITE<7_1 O <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> Cid <br /> FACILITY/SITE NAME - / Z CARE OF ADDRESS INFORMATION <br /> Il V l <br /> ADDRESS �q // NEAREST CROSS STREET ✓BaoMT ❑ F4RISFINAP ❑ STATE-A-4E <br /> ploam 0 OWM ❑ EmelrL+cExLY <br /> CITY NAME STATE ZIP OODE 7 SITE PHONE N,WITH AREA CODE <br /> r CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR <br /> -]4M ✓Box R INDIAN EPA ID N <br /> RESERVATION or N of TANSY <br /> ❑1 GAS STATION ❑3 FARM ER TRUSTLANDS ❑ 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 & ADDRESS — (MUST BE COMPLETED) <br /> NAME / V CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> //�� ❑ CORPORATION ❑ LOCAL-AGENCY 11 FEDERAL-AGENCY <br /> V, O O 0 ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME -T STAT ZIP CO -7� a� PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) 7 <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ 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)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: a <br /> IL of.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> a 3 <br /> CURRENTLOCALAOENCYFAC IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO ❑ — ! ' <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY� L V <br /> THIS FORM FUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFOR TION ONLY. V � <br /> FORMA(3-2-5&) ES/K \ <br /> l `' —C] 1 !/ DATA PROCESSING COPY AB/ S� l <br /> � T <br />