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STATE OF CALIFORNO WATER RESOURCES CONTABOARD /: u:.;•.'.A <br /> FORM `A': A <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> �iFo xN� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ T PERMANENTLY CLOSED SITE {-11 <br /> ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 96 <br /> C7 In <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) /CJ00 <br /> FACI /SITE NAME <br /> CARE OF ADDRESS INFORMATION 00 <br /> NEAREST CROSS STREET I/BOY loiMira@ ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY <br /> CITY NAM ❑ INDIVIDUAL ❑ COUNIYAGENCY <br /> STATE ZIP CODE <br /> SITE PHONE p,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOfl ❑ q PROCESSOR ✓Box CA <br /> IIINDIAN EPA 10 # <br /> ❑ 7 GAS STATION 3 FARM ❑ 5 OTHER RESERVATION TRUST LANDS or ❑ #of TANK'# <br /> EMERGENCY CONTACT PERSON(PRIMARY) ATTHISSITE <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> 1/130.to indicate ❑ PARTNERSHIP <br /> El CORPORATION ❑ STATE-AGENCY <br /> ❑ LOCAL-AGENCY ❑ F <br /> CITY NAME El INDIVIDUAL ❑ COUNTY-AGENCY EDERAL-AGENCY <br /> STATE ZIP CODE PHONE p,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS Box Ia indicate ❑ PARTNERSHIP <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 STATE-AGENCY <br /> CIN NAME ❑ WD"'DUAL ❑ COUNTY- FEDERAL-AGENCY <br /> AGENCY <br /> STATE ZIP CODE PHONE p,WITH AREA COOE <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. ❑ 111. ❑ <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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> J�COj�UNTYY## JURISDICTION# AGENCYN <br /> FACILITY ID# #Of TANKS at SITE <br /> IIuII <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> ��� O APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE <br /> /� ^� BUSINESS PLAN FILED DATE FILED <br /> V/ c�7. � 3a YES ❑ NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT "'� /� <br /> FEE CODE RECEIPT# <br /> BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PER FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON <br /> FORMA(3-2-tib) <br /> toDATA PROCESSING COPY <br />