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- -,w_•'._,-.-ter-•-"-.�.,�y.,y...--+,�.¢•��S!►�'"'If�ter-++ <br /> Stet or Ta <br /> STATE OF CALIFORNIAWATER RESOURCES CONTROL BOARD .� <br /> FORM `A': = UNDERGROUND STORAGE TANK PROGRAM . <br /> PERMIT APPLICATION <br /> FACILITY/SITE, INFORMATION and/or P <br /> SITE AGILITY/SITE <br /> COMPLETE THIS FORM <br /> FOR EACH F <br /> I IV <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT <br /> 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE I� <br /> 6 TEMPORARY SITE CLOSURE '� <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT CA <br /> 1. FACILITY/SITE INFORMATION &ADDRESS -- (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> PAAME <br /> NEAREST CROSS STREET `� W^6ctte ❑ PAk P ❑ S;AT6 AGDO <br /> Q171�I1 k ❑RATON 11TWAtY40a ❑ FE�Ax�G�Cr <br /> STATE 21P CODE SITE PHONE a,WITH AREA CODE <br /> `+A <br /> EPA ID n #o1 TANICs <br /> '. ❑2 DISTRIBUTOR ❑4 PROCESSOR E5ox 0 INDIAN RypION orAT THIS SITE <br /> ❑3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) ME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> EMERGENCY CONTACT PERSON{SECONDARY) <br /> PAYS: NAME(LAST.FIRST) PHONE R WITH AREA CODE DAYS: NA <br /> NIGHTS'. NAME{LAST,FIRST} <br /> PHONE N WITH AREA CODE <br /> PHONE#WITH AREA CODE NIGHTS- NAME(LAST,FIRST) <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> ❑ STATE-AGENCY <br /> ✓Box to indicate ❑ PARTNERSHIP ClFEDERAL-AGENCY <br /> MAILING w STREET ADDRESS C] CORPORATION <br /> ❑ LOCAL-AGENCY <br /> i ❑ INDIYIDVAL ❑ COUNTY-AGEhI PHONE q,WITH AREA CODE <br /> STATE ZIP CODE <br /> CITY NAME <br /> I <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENCY [j FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ CAUNTY•AGEN PHONE P.WITH AREA CODE <br /> STATE ZIP CODE <br /> GkTY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1]B01(INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: El <br /> AND CORRECT.FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE I <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY #of TANKS a1 SITE <br /> COUNTY# JURISDICTION# <br /> AOENCY# FACILITY If)# <br /> El 2 <br /> PHONE a WITH AREA CODE <br /> APPROVED BY NAME <br /> rMURRENT LOCAL AGENCY FACILITY iD# <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PERMIT NUMBER <br /> BUSINESS PLAN FILED DATE FILED <br /> LOCATION CODE CENSUS TRACT# SUPSOR DISTRICT COQE YES NO ❑ L <br /> r ZFEE CODE RECEIPT R BY. <br /> CHECKS PERMIT AMOUNT SURCHARGE AMOUNT <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 /> FORM A(3.2-68) DATA PROCESSING COPY 0 v`'-,, <br /> V � 1 NQ —k — LTJ <br />