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STATE OF CALIFORN19 WATER RESOURCES CONTR OARD <br />FORM `A': UNDERGROUND STORAGE TANK PROGRAM Y �o <br />SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE 0-9ORtkll <br />MARK ONLY i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE n I <br />1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />FACILITY/AE NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />CARE OF ADDRESS INFORMATION <br /># of TANKS at SITE <br />I I T�l <br />ADDRESS <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />NEAREST CROSS STREET <br />✓ Box to indicate ClPARTNERSHIP ElSTATE-AGENCY <br />❑ CORPORATION ❑ LOCAL -AGENCY El <br />❑ INDIVIDUAL 11 COUNTY -AGENCY <br />CITY NAME <br />,!S�LtjCA <br />PHONE #, WITH AREA CODE <br />PERMIT EXPIRATION DATE <br />STATE <br />ZIP CODE <br />CENSUS TRACT # <br />SITE PHONE #, WITH AREA CODE <br />TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR <br />❑ 1 GAS STATION [:]3 FARM <br />❑ 4 PROCESSOR <br />❑ 5 OTHER <br />✓ Box if INDIAN <br />RESEATION <br />TRUST LANDS or ❑ <br />EPA ID # <br />SURCHARGE AMOUNT <br /># of TANK's <br />AT THIS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />RECEIPT # <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br /># of TANKS at SITE <br />I I T�l <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE #, WITH AREA CODE <br />I11. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br /># of TANKS at SITE <br />I I T�l <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />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 # <br />Em <br />JURISDICTION # <br />I 1 1-1 <br />AGENCY # <br />E[ I I <br />FACILITY ID # <br />LL 1119 b- --:;I <br /># of TANKS at SITE <br />I I T�l <br />CURRENT LOCAL AGENCY FACILITY ID # <br />APPROVED BY NAME PHONE # WITH AREA CODE <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LOCATION CODE <br />CENSUS TRACT # <br />SUPERVISOR -DISTRICT CODE <br />BUSINESS PLAN FILED <br />YES � NO <br />DATE FI D <br />— Z <br />CHECK # <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPT # <br />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 />RM A (3-2-88) <br />DATA PROCESSING COPY <br />