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STATE OF CALIFORNO WATER RESOURCES CONTR91BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM �m <br /> SITE FACILITY/SITE, INFORMATION and/or ERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F-4 <br /> ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FA ITY/SITE NAM CARE OF ADDRESS INFORMATION <br /> M. aL <br /> ADDRESS NEAREST CROSS STREET ✓BOF irdirsle ❑ PARTNERSHIP ❑ STATE- <br /> AGENCY <br /> n ❑ APORAiION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> INGNIGGAL ❑ COUNTY AGENCY <br /> CITY NAME / STATE ZIP CODE SITE PHONE X,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS ❑ p DI RIBUTOR F—] 4 PROCESSOR ✓Box it INDIAN EPA ID # <br /> -11 GAS STATION 3 FARM ❑ 5 OTHER <br /> RESERVATION <br /> o ❑ X of TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> G , <br /> MAILING or STREET ADDRESSJ M/Box to'maicate El PARTNERSHIP STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X,WITH AREA CODE <br /> / C� <br /> ng- <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> C <br /> MAILING or STREET ADDRESS ✓Box to Ildl e ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ 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. ❑ 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 If AGENCY# FACILITY ID# If of TANKS at SITE <br /> o <br /> CURRENT LOCAL AGENC FACILITY ID ij, APPROVED BY NAME PHONE X WITH AREA CODE <br /> PERMIT NUMBER E P RMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LEN CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3lE;2& YES NO J <br /> CHI PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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 ONLY. / <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY 0 <br />