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STATE OF CALIFORN* WATER RESOURCES CONTABOARD 5fA'" <br /> FORM 'A'- UNDERGROUND STORAGE TANK PROGRAM _ a Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> U' 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 /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) ~ <br /> N <br /> F ITY/SITE NAMECARE OF ADDRESS INFORMATION <br /> ADD ESS NEAREST CROSS STREET ✓Buttidimie ❑ PPMNE�411P STATE-AGDO <br /> 0 OMPORATIOI 0 PAtTlENLY ❑ R'DEPAL-AGM <br /> 0 INDMDUAL 0 COUNTY AGENG( <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: BOX if INDIAN EPA IDN If o1 TANK's <br /> RESER❑ ❑2DISTRIBUTOR 4PROCESSOR ✓ YATION Or ❑ AT THIS SITE <br /> ❑ I GAB STATION ❑3 FARM ❑5OTHER TRUSTLANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(UST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> ( <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓So.to indicate 0 PARTNERSHIP D STATEAGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> Cl INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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. [:] 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION N AGENCY N FACILITY ID M 4t of TANKS at SITE <br /> = 10 1 C) I C) I o <br /> CNT CAL AGENCY FACILITY IDN APPRO D BY NAME PHONE N WITH AREA CODE <br /> pi <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUSTRACTM SUPERVISOR-DISTRICT COOE BUSINESS PU1N FILED DATE FILED <br /> '13-60 4 YES NOPOERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> DATA PROCESSING COPY <br />