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STATE OF CALIFORNIP WATER RESOURCES CONTRARIOARD <br /> �SE��eu�w�•��f. <br /> FORM IA': <br /> UNDERGROUND STORAGE TANK PROGRAM "'' "0 <br /> SITE FACILITY/SITE, INFORMATION and/or P MIT APPLICATION ,� ; o <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) O <br /> W <br /> FAG? /SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS ^ NEAREST CROSS STREET ✓Box to MOP ❑ PARTNERSHIP ❑ STATE AGENCY <br /> IRATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> E VPOOAL ❑ O <br /> YAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS ❑ 2 DI RIBUTOR ❑ 4 PROCESSOR '/Box if INDIAN EPA ID p <br /> RESERVATION or If of TANK's <br /> ❑ I GAS STATION FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE k WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE it WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE k 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 ✓Bo oointlicare ❑ PARTNERSHIP ❑ STATEAGENCY <br /> 1 C?4rll ❑ ORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> 1 _T1�.0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP ODE PHONE 4,WITH AREA CODE <br /> 11/53D-o <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicare ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY% JURISDICTION% AGENCY% FACILITY ID% If of TANKS at SITE <br /> M = = I Iboa. <br /> CURRENT L,AGENCY FACH TY N APPROVED BY NAME PHONE Or WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LO TI N CODE CENSUS TRACT O SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILED <br /> 13,3 YES NO --6- <br /> CHECK% PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT% BY: <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(3-2-88) <br /> a DATA PROCESSING COPY S <br />