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STATE OF CALIFORNIA WATER RESOURCES CONTROLNARD zEa <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° I o <br /> LlCOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F'J <br /> ONE ITEM Fg 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) G <br /> FACIL /SITE NAME t ^ CARE OF ADDRESS INFORMATION <br /> / <br /> ADDRESS _ NEAREST CROSS STREET ✓ iMiat C PARTNERSHIP ❑ STATE AGENCY <br /> S S. QC WRMUTION C LWALAGENCY C IMEULAGENCY 2 C INDNDUAL C COUNMAGENG/ <br /> CITY NAME STATE ZIP CODE _/ SITE P NE#,WITH AREA CODE <br /> IV CA C)y d 7 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PRO ✓Box if INDIAN EPA ID » #of TANK'S <br /> ❑ ESE <br /> I GASSTATION [:]3FARM OTHER TRUSTMATION LANDS or ❑ ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST RST) PHONE N 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_ADDRESSo indicate ❑ PARTNERSHIP C STATE-AGENCY <br /> ✓ <br /> CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH ARE-.,ACODE <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓ to indicate 11 PARTNERSHIP 11STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY C FEDERAL-AGENCY <br /> �✓/ C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ 11. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORREG.T. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION# AGENCY# FACILITY ID R #of TANKS at SITE <br /> ml = = oO <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E RATION DA <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED <br /> 9 �/ YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE 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 /> FORM A(3-2-BB) I <br /> vk DATA PROCESSING COPY \ I <br />