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STATE OF CALIFORNIA WATER RESOURCES CONTROL &RD <br /> t 9 <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM ,&0 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° �� o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SED SITE <br /> ONE ITEM <br /> El INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE U' ' <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> i FACILITY/SITE NAM CARE OF ADDRESS INFORMATION <br /> All &_46z <br /> ADDRESS NEAREST CROSS STREET ✓ r"- ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> El INDIVIDUAL ElCOUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 9'k <br /> TYPE OF BUSINESS: � 2 ISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ ❑ ❑ <br /> TRUSRESETiot <br /> RESET <br /> ATION or ❑ #of HIS SITE 1 GAS STATION 3 FARM 5 OTHER 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 /> NI HTS: NAME(LAS ,FIR ) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME V1�l/ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS / ✓Bo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> ___[ <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> �3 <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 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. 11. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> C <br /> OUN <br /> TY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> / <br /> L AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> ysE3 54 <br /> P RMIT APPROVAL DAT7E PERMIT EXPIRATION DATE <br /> r <br /> b CENSUS TRACT# SUPE VISOR- ISTRI T E BUSINESS PLAN FILED DATE FIL D <br /> ZYES NO PERMIT AMOUNT" SURCHARGE AMOUNT TFEE CODE 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 /> i <br />