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-�- ..,,.i..,.._-+prTar�9xmq;s4 vw"s-�_am..n ........r.-ap--•- m. ..+.�y z v'rnr't'V'.T,nT.rn'L'H <br /> STATE OF CALIFORNP WATER RESOURCES CONTRBOARD "^'T <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM w" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE14 <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 65 —4 <br /> j <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> F-� <br /> FAC /SITE NAME CARE OF ADDRESS INFORMATION <br /> S <br /> ADDRESS /� NEAREST CROSS STREET I/Sol to aelexx ❑ PARTNERSHIP ❑ STATE AGENCY <br /> O HEMI <br /> 1A ION Cl LOCAL UNTYAGEN ❑ FEDERAL AGENCY <br /> IB'NDIVIDUAI ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP ODE SITE PHONE p,WITH AREA CODE <br /> CA ✓�✓ &O <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> RESERVATION or Aof TANK'a <br /> E] 1 GASSTATION ❑ 3 FARM ❑ 50THEP TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE IT WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE It WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N 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 indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. ❑ if. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION M AGENCYTIL FACILITY ID Al M of TANKS at SITE <br /> 0 1 (2 <br /> CURRENT LOC/1L AOE�FACILITY ID It APPROVED 8Y NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER/`/ --/x PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> DE CEN TRAC� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ❑ DAT FILED <br /> 3 /J� YES NO <br /> PERMIT AMOUNT SURCHARGE AM UNT FEE CODE RECEIPT if 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(3-2-88) <br /> DATA PROCESSING COPY 9 <br />