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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> f� T <br /> S •••�useel•.'yf. <br /> FORM `A': 1 <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> /r COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY En"I NEW PERMIT ❑3 RENEWAL PERMIT E]5 CHANGE OF INFORMATION ❑ 7 P Y CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Q� —4 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) 00 <br /> FACILITY/SITE NAME I CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Box to w6cale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ElLOCAL-AGENCY 11FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA D ## <br /> RESE❑ I GAS STATION [:]3 FARM ❑5 OTHER TRUST LANDS ATION or ❑ Mot t <br /> AT THIS iS SSITE <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 If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. 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: 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> / 10 1 ? / <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT#--- I I BY: <br /> ENNIS <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST <br /> FORMA(3-2-t38) JR MORE TANK PERMIT FORM 'B'APPLICATION(S), U�S THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> DATA PROCESSING COPY <br />