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s <br /> STATE OF CALIFORNO WATER RESOURCES CONTROBOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM rea <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �D `P ,l o <br /> C 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 5 <br /> CD <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILI /SITE NAME 4 1-- CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓fttoirdwsk ❑ PAAfNERSHIP ClSTATE-AGENCY <br /> Cl CORPOPAGON ❑ LOCAL AGENCY [I FEDERAL AGENCY <br /> ClINDIVIDUAL [ICOUNTY AGENCY <br /> F CITY N STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID n _ #of TANIN <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION F—] 3 FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> EMERGENCY CONTACT PERSON(PRIMARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) <br /> PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP 73STATE-AGENCYCl CORPORATION ❑ LOCAL-AGENCY ClFEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION &ADDRESS- 'MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPORALON ❑ OUNTLOCAL-AGENCY <br /> AG NCV ClFEDERAL-AGENCY <br /> NU <br /> STATE ZIP CODE PHONE N.WITH AREA CODE <br /> CITY NAME <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: L ❑ 1L ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> FPERMITHTUMBER <br /> DICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 3 DAPPROVED BY NAME $$HMO NWITHAREACODE <br /> Y IDX P MITEXPIRATIONDATE PERMIT APPROVAL DATE <br /> DA------- <br /> LOCATION <br /> E FILED <br /> ECHECK* <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS YEN FILED NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> 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 0 Y. <br /> \ FORM A(3-2-88) --_ <br /> DATA PROCESSING COPY <br />