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OF <br /> STATE OF CALIFORNIA-' WATER RESOURCES CONTRG,,--,JOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM ; <br /> z <br /> SOTS FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' . , I o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 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 Cao <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) IV <br /> N <br /> FACILITY/SITE NA 4NEARESf <br /> F AD RESS INFORMATION <br /> ADDRESS CROSS STREET ✓Box b nkat' ❑ PMRTIIE WIP ❑ STATE-AGENCY <br /> / ❑ CORPORATION ❑ LOCAL-480 ❑ FMM&-AG80 <br /> L ❑ INDMWAL ❑ WJNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID# #of TANK'sl <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ATION or ElAT 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 /> 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 /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.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 Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl 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. ❑ IL ❑ 111.❑ <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) ___7DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> [= I I I I I I I I II�1 [3 h u Ll I I <br /> CURRpsoyLOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> GC <br /> PERMIT NUMBER PERMIT.APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT• SUPERVISOR-DISTR CODE BUSINESS PLAN FILED DATE <br /> YES NO <br /> CHECK# PERLt1T AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> L <br /> THIS FORM DUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERw FO RM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION Y. <br /> RM A(3-2-88) <br /> DATA PROCESSING COPY <br />