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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': ° <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION (o <br /> FQCOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 EW PERMIT F—] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE L.L. <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE t —4 <br /> I� <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> 00 <br /> FACILITY/SI E 4Z Ego kE5[ CARE OF ADDRESS INFORMATION <br /> P-1 <br /> ADDRESS NEAREST CROSS STREET ✓Bm WiMitale ❑ PAAHHJJyyDDCLHHIP ❑ STATEAGDO <br /> SO • 1 yy�� 1 Cl CORPORATION U3RffA AGRI Y ❑ FEDERAL AGENCY <br /> tU 0,A IV A L Cl INOW0,14 ❑ COUNTY- <br /> AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE If,WITH AREA CODE <br /> k CA 3 7 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROC R ✓Box if INDIAN EPA ID p If of!AN <br /> ❑ 1 GAS STATION 3 FARM ER RESERVATION or <br /> E] TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST,FIRST) �/J PHONE M WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE 4 WITH AREA CODE <br /> N& l <br /> NIGHTS: NAME ILA T, IRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Pc5CA nEgnHA 6 .SIS 121 <br /> MAILING or STREET ADDRESS 1/80x to indicate ❑p ,P�AR�TNERSHIP 13STATE-AGENCY <br /> 11 1/ <br /> llY- A-AGENCY ❑ FEDERAL-AGENCY <br /> V W ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> �✓ '2Zct3 <br /> III. TANK OWNER INFORMA N & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓80x to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(f)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. 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 M JURISDICTION M AGENCY M FACILITY ID M N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> = 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION C DE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED <br /> Z YES O NO 2 <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE I I BY: <br /> / THIS FORM MUST BE ACCOMPANIED BY AT LEAST I1)OR MORE TANK PERMIT FORM 'B'APPLICATIONIS), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> (FORMA(3-2-SBI <br /> WDATA PROCESSING COPY <br />