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STATE OF CALIFORNIA WATER RESOURCESCONTROrBOARD hE �"``s <br /> FORM `A': _ 'm <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE C I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - to <br /> ( COMPLETE THIS FORM FOR EACH FACILITY/SITE `"n°Px�F <br /> MARK ONLY NEW PERMIT _ ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERM LOSEO SITE N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE (J/ 4 <br /> 12111 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) Cn <br /> C11 <br /> FA /SITE NAME CARE OF DDRESS INFORMATION <br /> 4 /♦L// <br /> AOD ESS NEAREST CROSS STREET ✓ n@cah ❑ PARMERSIIP Q STATE-AGEND <br /> B LORroMTIDN ❑ .0MAG90 ❑ FEOBabAGENa <br /> ❑ INDMGUu ❑ CoUN1Y#GBICY <br /> CIrY NAME ATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> b CA d �l- ?[� z <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P ESSOR ✓Box if INDTICIAN EPA ID If M M TANK1 <br /> ❑ 1 GAS STATION ❑ 3 FARM S OTHER TRUSTLANDS <br /> or ❑ vV ATTHIESME ds <br /> EMERGENCY CONTACT PERSON(PRIMARY) EM GENCY CONTACT PERSON (SECONDARY) <br /> DAV AME(LASTt,FlRST) PHONE N WITH AREA CODE DAYS: VAME(LAST,FIRST) PHHO N WITH AREA CODE <br /> n.� clJ A d 'I <br /> NIGHTSNAME(LAST,FIRST)J PUH6N WITH AREA CODE NIGHTAME(LAST,FIRST) PHON N WITH AREA CODE 'I <br /> o A S <br /> 11. PROPER OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME & CARE OF ADDRESS INFORMATION <br /> Is.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 N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or sTF&Er ADDRESS ✓Box W indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: I. II. ❑ IR❑ <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 N JURISDICTION a AGENCY N FACILITY ID N N of TANKS at SITE <br /> o U <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME ` PHONE N WITH AREA CODE <br /> z S <br /> PERMIT NUMBER PI APPR VAL DATE PE IT E%PI ATIO DATE <br /> (I �i <br /> LOCATION CODE CENSUS TRACTSUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE LED <br /> q <br /> YES NO Z7 1� 1 <br /> CH K b PERMIT AMOUNT SURENIAI AMOUNT FEE CODE RECEIPT N 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 /> 1 FORM A(3-288) <br /> '.I DATA PROCESSING COPY --- <br />