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STATE OF CALIFORNI9 WATER RESOURCES CONTRAOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM = " o Z <br /> SFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION GZ7 PERMANENTLY CLOSED SITE I"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) Ln <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Cy <br /> ADDRESSt. ' ` A IP 0 STATE ADEN <br /> NEAREST CROSS STREET ❑ CpRIlmIPoBATION ❑ LOUNTYAENLI' ❑ FEDERAL <br /> ❑ INDIVIDUAL Cl COUNTY <br /> CITY NAME /^� V V /✓ STATE ZIP CODE SITE PHONE p.WITH AREA CODE <br /> J CA 5 1 aO � <br /> 5J <br /> TYPE OF BUSINESS: ❑p2DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID p /p��`/�_ /� , p of TANK's <br /> ❑ 1 GASSTATION �9 FARM ❑ 5OTHER <br /> RESERVATION <br /> LANDS or ❑ / I!N/ n — AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS.' NAME(LAST.FIRST) PHONE p WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE p WITH AREA CODE <br /> V ao � - - <br /> NIGHTS: NAME(LAST,FIRST) PHONE p ITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE p 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 mclic.t. ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> r <br /> MAILING or STREET ADDRESS -/Box to,,do.I. ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY <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)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. v 11. ❑ 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 R JURISDICTION# AGENCY# F CI IDM 'yI Sn Of of TANKS At SITE <br /> [� 0 al 0 <br /> CURRENT LOCAL AG C FACILITY ID p APPROVED B NA E PHONE p WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PE ORATION DATE <br /> LOCATION CO DE q SUSTRACT• SUPERVISOR-DISTRICT CODE BUSINESS,P SNDN FILED ❑ DATE FI ED <br /> CHE K M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p 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(3-2-8B) <br /> DATA PROCESSING COPY <br />