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V�y 9/. , LI//,y!!!_ c�7 <br /> OF <br /> STATE OF CALIFORNIN WATER RESOURCES CONTROBOARD <br /> { 7 <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM _�` al T <br /> z p z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> PTS <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITELD <br /> MARK ONLY F-11 NEW PERMIT 3 RENEWAL PERMIT E915"CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITZ: INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Box Io indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CARPGHAL ❑ COUNTY-AGEN ❑ FEDERAL-AGENCY <br /> ❑ INDMIDUAL ❑ COUNTY�AGEkCY <br /> CITY NAME STATE ZIP CODE S E PHO #,WITH AREA CODE <br /> CA 3 6 3 61)7 <br /> EPA ID IN <br /> TYPE OF BUSINESS: .❑ 2 DISTRIBUTOR 4PR0 R #of TANK's <br /> RESERVATION or <br /> 1 GAS STATION O 3 FARM THEA TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE ftWITHAREA CODE DAYS NAME(LAST,A TI PHO7NE#WITH A�RyE`A]CODE <br /> 7/ X <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> LAMET L / <br /> I1. PROPERT WNER INFORMATION &ADbRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> li L l � <br /> MAILING or STREET DRESS ( ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> A/'y ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> � ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP COOP PHONE#,WITH AREA CODE <br /> /7z <br /> III. TANK OWNER INFO MATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <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 /> 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. II. � 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&&GNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> F <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> �' � aAGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERN,UMOER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-D STRI T CODE BUSINESS PLAN FILED DATE FILEYES NOPERMIT AMOUNT SURCHAR&AMOUNT FEE CODE RECEIPT# Y: <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 ON <br /> RMA(9-2-88) <br /> DATA PROCESSING COPY <br />