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`.. ..YU RIBA •.E <br /> STATE OF CALIF 0R11 A WATER RESOURCES CONTROL BOARD sa <br /> w . _ aM�.m <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM w Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION cqi oA ;P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK:ONLY fNEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITEONE M ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FAC$LITY/SITE NAME q <br /> W Q EAREST CROSS STREET ✓Box to whale Q PARTNE%HIP ❑ STATE-AGENCY <br /> ADDRESS ❑ CORPOR PON ❑ LOCAL-AGENCY Q FEDERAI AGENCY <br /> 0 y '❑ INRNIOl1Al ❑_ COl1NTYAGENCP <br /> ct3r STATE ZIP COO, SITE PHONE H,WITH AREA CODE <br /> CITY NAME CA <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR -'(Box if INDIAN EPA IDN #Of TANK'S <br /> ❑ ❑ RESERVATION or ❑ <br /> AT THIS SITE <br /> ❑ f GASSTATION ❑ 3 FARM ❑5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> DAYS: NAME(LAST,FIRST) <br /> NIGHTS NAME(LAST.FIRST) ! PHONE#WITH AREA CODE NIGHTS' NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> I1. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS I NFORMATI ON <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Q COUNTY-AGENCY <br /> STATE ZIP CORE PHONE#,WITH AREA CODE <br /> CITY NAME <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ClSTATE-AGENCY <br /> C] CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZSP CODE PHONE#.WITH AREA CODE <br /> CITY NAME <br /> IV, LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(11 BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ HI.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# <br /> AGENCY# FACILITY ID# #of TANKS al SITE <br /> L _i__L_L1 I <br /> 1;�m L <br /> I <br /> __L_Lj I 'I <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> APPROV BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> ERMIT EXPIRATION DA <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR ICT CODE BUSINESS PLAN FILED DATE FILED <br /> � QQ <br /> (0 ) �+ YES ❑ NO 4J-Z-Q <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> 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(3-2-88) <br /> DATA PROCESSING COPY <br />