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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': \ <br /> UNDERGROUND STORAGE TANK PROGRAM ;yRm <br /> SITE /FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION `S /Ys� <br /> v COMPLETE THIS FORM FOR EACH FACILITY/SITE ,;_ let <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION °`.�, <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ T Pp NENTLY CLOSED SITE TV <br /> ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 9 / rn <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) cr <br /> FACILITY/SITE NAME Fla <br /> v0-,/ /], CARE OF ADDRESS INFORMATION <br /> ADDRESS .- <br /> / NEAREST CROSS STREET /guo,� PMiMP <br /> 4J V El MRATE AGOiCy <br /> ME <br /> �AIPOINIDN LOUNBAGNLY ❑ EFOEIt4 AGENLY <br /> CITY NAME ❑ INDVIWIS CE I,WHEN A <br /> STATE 21P CODE SITE PI1pryE p,WITH AREA CODE <br /> TYPE of BuslNess: <br /> CA 376 /S' �/7 - O Z <br /> 7 DISTRfiUTOq 1 ESSOq ✓B ItINDIAN EPA lu w <br /> ❑ I GAS STATION ❑3 FARM 5 OTHER RES VATION TRUST LANDS or ❑ N of TANK'% <br /> EMERGENCY CONTACT PERSON(PRIMARY) ASITE <br /> EMERGENCY CONTACT PERSON(SECOErpARY)RY) <br /> DAYS. NAME(LAST,FIRST) PHONE Al WITH AREA CODE GAYS. NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> NIGHTS: NAME(lA$T,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PHONE p WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMAI ION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 11 11 STATE-AGENCY <br /> CItt NAME <br /> Cl INDIVIDUAL ❑ COUNTYAGENCY <br /> FEDERAL-AGENCY <br /> STATE 21P CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY FEDERALAGENCYCITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOE INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. ❑ 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 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION* AGENCY* <br /> FACILITY IDN *of TANKS at SITE <br /> CURRENT LOCAL AGENCY FA ILI7YID* <br /> 2 N� / APPROVED BY NAME PHONE Y WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT E%PIRATION DATE I <br /> LOCATION CODE CENSUS TR CT If SUPERVISOR Ig7RICT CODE <br /> OI ^ 0 v I,// BUSINESS PLAN FILED DATE FIL <br /> I I' a YES NO (I <br /> CXECKN PERMIT AMOUNT SURCHARGE AMOUNT <br /> FEE CODE RECEIPT N Y. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLFFc THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-tl1)3) <br /> DATA PROCESSING COPY <br />