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STATE OF CALIFORNIx WATER RESOURCES CONTROZCBOARD <br /> FORM 'A': :'��,,, , ':•. <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE I ED <br /> MARK ONLY ❑ 1 NEWT$RMIT F] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED SITE ra. <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �J <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) to <br /> j FACILITY/SITE N /'^ CARE OF ADDRESS INFORMATION m <br /> ADDRESS � NEAREST CROSS STREET ✓ftbYticeb ClPAATNEIZmP ❑ STATE AGENCY/ 7G O NGI u1 � O LWAAGENCY ClFBXW.AUE <br /> CITY NAME S STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> l �- <br /> TYPE OF BUSINESS: f 2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID nA <br /> D I GAS STATION ❑ 3 FARM 5 OTHER ESERVLA ION o' ❑ N of TANK'S <br /> 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 CARE OF ADDRESS INFORMATION <br /> MAILING w STREET ADDRESS ✓Box toind,c.Ie ❑ PARTNERSHIP El STATE-AGENCY <br /> El ❑ LOCAL-AGENCY ❑ 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 w STREET gDDflE55 ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY❑ INDIVIDUAL ❑ COUNTYAGENCYCITY NAME STATE ZIP CODE PHONE 0,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: 1. [] if. 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 M JURISDICTION B AGENCY R FACILITY ID M X of TANKS BI SITE <br /> CURRENT LOCAL AGENCY FACILITY Ill# APPROVED BY NAME PHONE 4 WITH AREA CODE <br /> PERMIT NUMBER /CT' PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE D <br /> YES NO <br /> CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• Sy; <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST MOR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. (� <br /> .� FORM A(3-2-86) (t Tp�EL/`�,' 1) �\J <br /> G ��s - o ` - DATA PROCESSING COPY <br />