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STATE OF CALIFORNI00 WATER RESOURCES CONTROROARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM 7 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONr <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> [:] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED <br /> MARK ONLY F-1 1 NEW PERMIT SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) (� <br /> FACT TY/SITENAM CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bwlaine.le 0 PARTNERSHIP 0 STATE AGENCY Cl/� ❑ CORPORATION LOCALAGENCY0 FEDERAL AGENCY <br /> •_7 M ( , ❑ INDMOUAL ❑ COUNrvAGENCY <br /> STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> CITU NAME <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box d INDIAN EPA ID e K of TANK's <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH ARE]COOE <br /> NIGHTS' NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH ARE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS I/Box to Indicate Cl PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS %/Box to indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCALAGENCY0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> FT= <br /> CURRENT LOCAL AGENO FA ITY ID k APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER^ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED I DATE FItLj <br /> YES NOCHECK# PERMIT AMOUNT SURCHARG AMOUNT FEE CODE RECEIPT# <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 /> \J\l\ FORM A(3-2-88) • <br /> DATA PROCESSING COPY <br />