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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ...: ` <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE Z,, kCILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT Cil-CHANGE OF INFORMATION ❑ NTLY CLOSED SITE N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS - (MUST BE COMPLETED) SOD <br /> FACILITY/SITE NAMy CARE OF ADDRESS INFORMATION IL <br /> ADDRESS ^ [, NEAREST CROSS STREET ✓Bmbrtc! 0 PAMNEBSAP 0 SIATEAGENC1 <br /> 24 Q(�L 0p ` 0 OMFOATDN 0 LOMtoa LY 0 ROEIIN-AGENLY <br /> CITY NAME <br /> 0 AVMOIAIL ❑ WUIIIYdGENLY <br /> ! STATE ZIP ODE SITE PHONE#.WITH AREA CODE <br /> 1 (� cA f3 7 6 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOfl ✓ <br /> ❑ Box if INDIAN EPA ID N <br /> ❑ I GASSTATION ❑3 FARM NIV <br /> ❑ 5 OTHER TRUSTYL. S ATION nr ❑ AT NITS 817E <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE R 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 N WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to inoicale ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION Cl LOCALAGENCY0 FEDERAL-AGENCY <br /> CITY NAME ElINDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE R.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toinolcate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME CIINDIVIDUAL 0 COUNTY-AGENCY <br /> STATE 21P CODE PHONE p,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. ❑ IL ❑ 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 b SIGNATURE) GATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY F JURISDICTION 0 AGENCY F FACILITY ID F 0 of TANKS Rt SITE <br /> CURRENT LOCAL AGENCY FACILITY IDR <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> Go 0 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE t <br /> [CHECK <br /> TION OD CENSUS TRACT R SUPERVISOR-DISTIIICT CODE MUSINESS PLAN FILED DATE FILED j <br /> 7 -2— YES � NO <br /> R PERMIT AMOUNT SUR AMOUNT _ FEE E RECEIPT# BY: <br /> IG✓/� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t'^R MORE TANK PERMIT FORM 'B'APPLICATION(S), UN' ' ISIS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A 132-88) <br /> `�� DATA PROCESSING Cflov �../ <br />