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1 ' <br /> eE'aV Of JNf <br /> STATE OF CALIFORVA WATER RESOURCES COAL BOARD u <br /> FORM `A': _�� m" <br /> UNDERGROUND STORAGE TANK PROGRAM Z R o Ic <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C'�LIf00.N�0. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE rt4 <br /> 1 NEW PERMIT ❑ 3 RENEWALPERMIT CHANGEOFINFORMATION 7 PERMANENTLY CLOSED SITE r <br /> MARK ONLY ❑ �� <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITU <br /> ACILITY/SIT AM€ CARE OF ADDRESS INFORMATION <br /> i � 0f <br /> NEAREST CRO SS STREET ✓8abikce# ❑ PARINB6HIP ❑ SiATEAGENLY <br /> ADDRESS O I ; 1 ❑ WRR7R4TON ❑ LOGTYAGIIp ❑ FmEML AGEMLY <br /> ` ❑ INDMDAAL ❑ COUNTY AMM <br /> CIN NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> CA <br /> TYPEOFBUSINESS: 02DISTRIBUTOR ❑4PROCESSOR ✓Box if INDIAN EPA ID # If of TANKs <br /> RESERVATION or AT TRIS SITE <br /> ❑ I GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) <br /> PHONE If WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODENIGHTS: NAME(LAST,FIRST) PHONE N 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 ElSTATE-AGENCY <br /> ❑ CORPORATION <br /> A ❑ COUNTY AGE CYPORTION ❑ FEDERAL-AGENCY <br /> ND <br /> STATE ZIP CODE PHONE It,WITH AREA CODE <br /> CITY NAME <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 EISTATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE A.WITH AREA CODE <br /> CIT'NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(f)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BMX LEGAL NOTIFICATION AND BILLING: I. It. El III. Ll <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 8.SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY IDM If of TANKS at SITE <br /> auaa <br /> CURRENT LOCAL AGENCY FACILITY ID If q�\ <br /> APPROVED BY NAME PRONE M WITH AREA CODE <br /> PERMIT APPROVAL DATE U PERMIT EXPIRATION DATE <br /> PERMIT NUMBER <br /> LOCATION CODE CENSUS TRACT If SUPERVISOR-DISTRI TCODE BUSINESS <br /> ,,P SN FILED NO <br /> ❑ DATE FILEDI, Y� <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT If BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST f 11 OR MORE TANK PERMIT FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2 88) . 0, <br /> DATA PROCESSING COPY <br />