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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD s`� <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �'" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� o <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE `'���ee�`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE w <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS O NEAREST CROSS STREET ✓Bm b' 0 PAMNUISHP 0 STATE-AGENC/ <br /> 0 NDmm Cl LOCALAGENCY <br /> [IFEpE0.gL-AGENCY <br /> / <br /> CITY NAME / STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> PdV/ CA �Z/ <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d P ESSOR ✓Box iI INDIAN EPA ID p <br /> ❑ I GAS STATION 3 FARM 5 OTHER RESERVATION or - #of TANK# / <br /> ❑ TRUST LANDS ❑ AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> AST, <br /> DAYS: NAME(LFIRST) � ' PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> n1 - ZI -7 ("NN e-I 20 _2! 77 <br /> NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS. NAME(LAST IRST) PHONE If WITH AREA CODE <br /> Sa wvei Se-w1R- <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME ,n ^ ` ' CARE OF ADDRESS INFORMATION <br /> ✓ v k' ry <br /> MAILING or STREET ADD ESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> �T <br /> 6 A_A4 A"f IN C RATION 0 LOCALAGENCY ❑ FEDERAL-AGENCY <br /> V DIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP J l0 PHINEI WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) 'i <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓B to indicate Cl PARTNERSHIP C STATEAGENCY <br /> ORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL 0 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 BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it.rl 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 If AGENCY# FACILITY ID# If of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE <br /> V A-/J <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACqT#o SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> D �7 O D 710 YES 0 NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It BY: ' <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />