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0 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 5E'�ur; Nf <br /> FORM 'A,. J <br /> "UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACILITY/SITE I C] <br /> C�l�lOF Nor <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE F-'• <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE C" <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) O) <br /> FACILITY SITE NAME CARE OF ADDRESS INFORMATION C" <br /> r ADDRESS <br /> NEAREST CROSS;STREET ✓Ibrbirdu* ❑ PARTNEf IF ❑ STATE-AGENCY❑ COWMTION ❑ LOCAL-AGENCY ❑ FEOENAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATEIP CODE SITE PHONE N,WITH AREA CODE <br /> l CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> I GAS <br /> U STATION ❑3 FARM E]5 OTHER RESERVATION or El AT <br /> of TANK i <br /> ITRUSTLANDSAT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: LAST,FIRST NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME <br /> ( ) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &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 /> 11 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &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 NAtf STATE ZIP CODE PHONE N,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. El II. ❑ III.❑ <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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION ff AGENCY M FACILITY ID# N of TANKS at SITE <br /> ® O C)_I 'D_I'= _ _ 1 _ 0101 O <br /> lc_z <br /> CURRENT LOCAL AGENCY FACILITY ID 0 ( � APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CEN�SIJB TRACT it SUPERVISOR-DISTRICT CODE BUSINESS YPLAN❑ FILED NO ❑ DATE I�jl <br /> aql m <br /> CHECK 1 1 PERRMM`IT AAMOODUNT7v� BURCMAROE AMOUNT FEE CODE RECEIPT N 3 BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)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 />