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STATE OF CALIFOR6rA WATER RESOURCES CONTTICL BOARD <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 ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANEN LY CLOSE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF AD RESS INFORMATION <br /> N <br /> ADDRE ]NEnARESTCROSSSTREET ✓ biigreV ❑ PARTNEIEMIP El STATE AGENCYQ /'t ❑ IXNWIUTIGN ❑ LOCALAGDICY ❑ FEDERAL-AGENCY <br /> ❑ INWMDIAL ❑ COUNIYAGRICI <br /> CITY NAME ZIPCODE SITE PHONE a,WITH AREA CODE <br /> SZ <br /> TYPE OF BUSINESS: {❑ 2 DISTRIBUTOR ❑ /PROCESSOR '/Box if INDIAN EPA ID a _ <br /> ❑ I GASSTATION ❑ 3 FARM SERVATION <br /> S OTHER TRUST AND'TIOh GF ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,F RST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> s�Je� <br /> NIGHTS: NA (LAST.F ST) PHONE a WITH AREA C DE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> H. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME / CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to iftcale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE ^^ PHONE a,WITH AREA CODE <br /> ��0,6 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Mlcate O PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADM$$SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. If. ❑ Ill. ❑ <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 /> COUNTY R JURISDICTION R AGENCY R FACI:= I <br /> M of TANKS at SITE <br /> 3 <br /> URRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE F WITH AREA CODE <br /> RP a3 <br /> ["RI­� PEIllllfff APPROVAL DATE PERMIT EXPIRATION DATE <br /> [CIHECK <br /> CODE CENSUS TRACT SUPERVISOR-013MICT CODE BUSINESS PUN FILED DAME D <br /> 3 2 YES NO Z1190 <br /> r^ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k BY. <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 ONLY <br /> FORMA(3-2-88) ✓ <br />