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y . OF TN <br /> STATE OF CALIFORNIP WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRA mo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPMPLETE THIS FORM FOR EACH FACILITY/SITELIC TIO , Y �= <br /> n, CO `' !O <br /> v C'4 CIFO RNP <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ -&PERMANENTLY CLOSED SITE , <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) �Ib <br /> FACT /SITE NAME CARE OF ADDRESS INFORMATION ' <br /> ADDRE S N AREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /� <br /> 1:1 CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> 1 )er-S ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> }� CA <br /> TYPE OF SINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR <br /> Boxf INDIAN EPA ID # <br /> TION or #of TANK's <br /> 1 GAS STATION ❑3 FARM ❑ 5 OTHER T LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#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 /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. 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 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: 1. ❑ 11. ❑ 111.❑ <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 /> EE 13a <br /> CU NT LOCAL AGEN4FALITY ID# APPROVED BY NAME PHONE 8 WITH AREA CODE <br /> UI <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS YPLAN FILED NO ❑ DAT!E�FILEPCHECK# PERMIT AMOUNT SURCHARGE AMOUNTODE RECEIPTK BY: <br /> J <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST OR MORE TANK PERMIT FORM `B'APPLICATION(S), U. SS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> RM A(3-2-88) �v <br /> �j <br /> i-\ DATA PROCESSING COPY <br />