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STATE OF CALIFORNM WATER RESOURCESCONTR6fBOARD QIZO <br /> FORM `A':SITE UNDERGROUND STORAGE TANK PROGRAMFACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONCOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ / NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 4 <br /> 61 Cq <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) cn <br /> FACILITY/SITE NAME y (� CARE OF ADDRESS INFORMATION µ <br /> C ad .]47I-�' <br /> ADDRESS ` NEAREST CROSS STREET ✓gN bndaw ❑ PAIRNR59P ❑ 5FATE-AGBILY <br /> Y3& S. of f- o0 r�POMwMDUUI« o LOCAL 0 FEDERAL-AGENCY <br /> CITY NAME STAP CODE SITE PHONE N,WITH AREA CODE <br /> TiCA 533( <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PflOCES$Ofl ✓Box if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑5 OTHER TRUSTmLANDS ION Cr ❑ A?NA5M7E <br /> S <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N 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 /> � a <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> O CORPORATION ❑ LOCALAGENCY0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME MM / CARE OF ADDRESS INFORMATION <br /> -t7 <br /> MAILING ar STREET ADDRESS ✓Box to',odicate Cl PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. ❑ II. ❑ 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION N AGENCY N FACILITY ID N X of TANKS at SITE <br /> mI I I y / I ly 1-5-1 <br /> CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE N WITH AREA CODE <br /> EG-RDI <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAT M CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESSPLAN❑ED NO <br /> ❑ DSF,j/ Q <br /> oft <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N /f 3'B/y: f <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL<::� <br /> VFORM A(5-2-081 <br /> DATA PROCESSING COPY <br />