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vr <br /> COT <br /> STATE OF CALIFORNIf WATER RESOURCES CONTROL BOARD N ;`'fi e <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY Efi NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PER MAN OSED SITE fV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C. <br /> Q: <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) p�D <br /> FACILITY/SITEIN E CARE OF ADDRESS INFORMATION <br /> a,S S /1i Wf <br /> ADDRESS NEAT CROSS FEET B.to Idute 11 PARTNERSHIP El STATE AGENCY <br /> 3967 ElCORPORATION ❑ LOCAL El FEDERAL <br /> ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAMESTATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> G 1� L11' CA ad� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 0 4 11 ✓Box if INDIAN EPA ID pRESE /) <br /> E] 1 GASSTATION ❑3 FARM 5 OTHER TRUSTYATION LANDS e ❑ AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> 4i)S 3 5--3a L- - <br /> NIGHTS'. NAME( ST,FIRST) PHONE IT WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> S sArME <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ' L <br /> MAILINGr ST <br /> oFEET A 55 -/Box to indicate CJPARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION L1LOCAL-AGENCY 11 FEDERAL-AGENCY <br /> A ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> C 9yarl-d97 <br /> III. TANK OWNER INF MATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/B..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. ❑ it. ❑ It. ❑ <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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> am [� OD / D� 1000 / <br /> I\P CURRENT OCALi GENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> \ PERMIT NN(UUMIII PERMIT APPROVAL DATE PERMIT EXPIRATION ATE <br /> V\\� LOCATLONC DE � CENSUS TRACT# � PERVISOR-DISTRICT CODE BUS/ESS EANIR D ❑ DTE FILED <br /> NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY.'/ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 1 t R MORE TANK PERMIT FORM B'APPLICATION(S), UNTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-SB) r <br /> DATA PROCESSING COPY <br />