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ll'—Y'#'°. • ^WAt— `�.17 -"444` <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM = " ; <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 2 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> [7MARK,ONLY ❑ t NEW PERMIT ❑3 RENEWAL PERMIT E CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE rEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ClarkA&V Ic , (10 <br /> ADDRESS NEARESTCROSSSTREET ✓Bm i <br /> wloe 11PAAINSISIP E3STATEAGD&F <br /> ZO 'IrElDNMMToN ❑ LOCAL-AMILY ❑ FEDEMLAGOO <br /> ❑ INDIVIDUAL ❑ cojmAGENC( <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA IM-10157- <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I -/Box A INDIAN EPA ID It <br /> RESERVATION or #of TANICe <br /> ❑ I GAS STATION ❑3 FARM ❑ S OTHER TRUST LANDS ❑ AT 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 N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to iMicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 13 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU 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 ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ 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. ❑ I. ❑ III. ❑ <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) DATE <br /> LOCAL AGENCY USE ONLY <br /> 1 <br /> COUNTY# JURISDICTION R AGENCY# FACILITY ID B k of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE N WITH AREA CODE <br /> 2b <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 0' LOCATION CODE CENSUS TRACT* SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE IUD <br /> V Z YES ❑ NO Z <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> J THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNI En THIS IS A CHANGE OF SITE INFORMATION ONLYi- V <br /> FORM A(3-2-88) <br /> _V•1 �- DATA PROCESSING COPY <br />