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STATE OF CALIFORNIA WATER RESOURCES CONTROL OARD ;z«;^','F <br /> ' �„„mss; <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM °° �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> r_ COMPLETE THIS FORM FOR EACH FACILITY/SITE � q <br /> C'<IIiOFN\P IY <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 157 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 156 r <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) V <br /> r <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> r I0- <br /> ADDRESS NEAREST CROSS STREET -/ButMm El PARTNERSHIP 11STATE-AGENCY <br /> Ill CORFORAMN ❑ LOCAL-AGENCY ❑ FEDERAL AGEKN <br /> 11INDMDIAL ❑ COUIEY-AGENM <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box H INDIAN EPA ID N <br /> RESERVATION or ❑ k of TAN" <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 N WITH AREA CODE DAYS. NAME(IAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(I-AST.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 io0icate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓BOX to iriGicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <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: I. ❑ IL ❑ 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# JURISDICTION# AGENCY# FACILITY ID# At of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> .3rete 60 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECKO <br /> CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED <br /> YES � NO ❑ I (� <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: l �./ <br /> THIS FORM MUST BE ACCOMPANIE BY AT LEAST(13-OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLF%S THIS IS A CHANGE OF SITE, �0/IINNFFORMATION ONLY. � <br /> FORM A(3-2-88) ' 0 <br /> 1� C , �. DATA PROCESSING COPY <br />