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SF�Or. l <br /> STATE OF CALIFORNI.0 WATER RESOURCES CONTRA OARD <br /> FORM `A': O <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> r <br /> SITE )FCILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq�FOR�P <br /> MARK O Y 1 NEW PERMIT ❑ 3 RENEWAL PERMIT El <br /> CHANGE OF INFORMATION PERM Y CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAM CARE OF ADDRESS INFORMATION <br /> VM AFL (1wv <br /> ADDRESS NEAREST ROSS STREET �CORPORATION <br /> ClTNERSHIP ❑ STATE-AGENCY <br /> / / /�AAL-AGENCY ❑ FEDERAL-AGENCY <br /> UNTY-AGENCY <br /> CITY NAME / (` �/ STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE <br /> �/� _ (�f <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK'S <br /> 5 OTHER RESERVATION or ❑ AT THIS SITE L/ <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <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. ❑ 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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> Ll I j [ yl <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> CURRENT LOCAL AGE Y F�ICILITY ID� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPE OR-DISTRIC COD BUSINESS PLAN FILED DATE FILED <br /> ® 7 (, YES ❑ NO ❑ 7 '� 7 <br /> L <br /> RECEIPT# BY: <br /> CHECK#' PERMIT AMOUNT SU CHARGE AMOUNT FEE CODE <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 /> ((( ��\ <br /> .v <br /> FORM A(3-2-88) S <br />