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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> yEn� yryA <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM �e <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 PERMANENTLY CLOSED SITE IV <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> -50 C" <br /> 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) to <br /> FACILIN/SITE NAME > CARE OF ADDRESS INFORMATION <br /> — I VAILEY �N/h./ScGGt- AN 41 k— <br /> ADDRESS NEAREST CROSS STREET ✓8mz rdtaa D PARTNERS* D STATE Awn <br /> D � G0 FEORLAGEC <br /> 0 INoNNIDUAL O CODUNN-AENCYS. <br /> CIN NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 4S46G <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR 4 PROCESSOR %//Box OINDIAN EPA ID N <br /> ❑ RESE <br /> 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TTRUSTYATION AT THHISIS SITE <br /> or ❑ #al TE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box to indicate D PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP D STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOJ(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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACtLITY ID If If of TANKS at SITE <br /> [ail I <br /> 1 ' r <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE If WITH AREA CODE <br /> T,cl dAz� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Z3. 90 s YES NO ❑ JI <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST If)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. �\ <br /> —Ay 1 � DATA PROCESSING COPY �•• <br />