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0 STATE OF OALIFO►RNI WATER RESOURCES CONTR OARD «:gip` �` ` <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM rim <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> F <br /> RK ONLY F-111 NEW PERMIT F—] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION El7 PERMANENTLY CLOSED SITE <br /> NE ITEM F+p INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) I <br /> FACILITYISITE NAME CARE OF ADDRESS INFORMATION <br /> it 9 A <br /> ADDRESS NEAREST CROSS STREET +�✓��,�Aq_IF <br /> °indicate 11 PARTNERSHIP El STATE-AGENCY <br /> El INDIVIDUAL El COUNTY-AGENCY ON 11 ElFEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE SI�'7PHONE#,WITH AREA CODE I0 <br /> �f✓V I�7.1� CIA a'C <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # <br /> RESE[:] F7] TTRUSTMATIONLANDS or ❑ f1/f! AT H0 of EIS SITE <br /> OAS STATION3 FARM 5 OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE#^7WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> 1:5if2 CIT <br /> NIGHTS: NAME(LA- ,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST)Z PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET App SS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ,ii /� ❑ ORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> </ C,3+IINDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE#,WITH AREA CODE <br /> 3D <br /> Ill. TANK OWN INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS FORMATION <br /> MAILING or STREET ADDRESS toindicate ClPARTNERSHIP LlSTATE-AGENCY <br /> tn CORPORATION ❑ LOCAL-AGENCY El FEDERAL-AGENCY <br /> ElINDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 30 <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: 1. ❑ it. ❑ 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 /> aE I I I I El I I I o I in I r Iq 141 I I [I le Fol�]_ <br /> CURRENT LOCAL ENCY FACILITY ID# APPROVED BY N E PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE in PER mrr EXPIRATION DATE <br /> LOCATION CO E CENSUS TRACT# SU FIVI R-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 YES [] NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNTFEf CODE RECEIPT# Y: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS 1S A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-138> I I <br /> DATA PROCESSING COPY "� <br />