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STATE OF CALIFORNIA WATER RESOURCES CONTROROARD A <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION co <br /> �'I IIFOP��P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET R PE <br /> ORATION ❑ LDCAL AGENCY [IFEDEFAGAGENCY <br /> ❑ INDIVIDUAL ❑ COUNttAGENCY <br /> CIT`I_NAME <br /> STATE ZIP CODE ITE PHONE# WITH AREA CODE <br /> G� CA S <br /> TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID # #of TANK's <br /> ❑ <br /> 1 GAS STATION 3 FARM 5 OTNEfl RESERVATION or TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIR T PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAS,FIRST)^ ZuSPHONE#WITH AREA CODE NIGHTS: NE(LAST,FIRST) PHONE#WITH AREA CODE <br /> J <br /> II. PROPERTY OWNER INFOR ATI N &ADDRESS - (MUST BE COMPLETED) <br /> ME CARE OF ADDRESS INFORM N <br /> MAILING or STREET ADDRESS Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> �RPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> 10 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE d.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NA E CARE OF ADDRESS INFORMATION <br /> ✓ indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRE <br /> [I CORPORATION <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU N6ME STATE ZIP CODE P ONE#,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. ❑ II. ❑ 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) GATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> OUI lolc) 1 / 1aI'-2k;d <br /> CURRENT LOCAL/AGENCY FACILITY ID# APPR ED BY NAME PHONE#WITH AREA CODE <br /> PERMIT N BER V PERMIT APPROY L DAT ER IT EXPIR ION DATE <br /> L <br /> CENSUSTRACT# S ER I R-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 1GOYES NO <br /> PERMIT AMOUNT SUR ARGE 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 /> FORMA(3-2-65) <br /> • DATA PROCESSING COPY <br />