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I*V af13 -/3 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAMo <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1 <br /> 10 <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SRE NAM CARE OF ADDR S INFORMATION <br /> . . Q'.YTi <br /> ADDRESS NEAREST CROSS STREET ✓_ ie Q PARTNERSHIP Q STATE-AGENCY <br /> eORATION Q IDEAL AGENCY Q FEDEAALAGENLY 0000 <br /> ❑ INDVIWAI ❑ OCUNF`AGENCY <br /> CITY NAME STATE ZIPCODE SITE PHON N,WITH AREA CODE <br /> CA 1 �T <br /> TYPE OF BUSINESS ❑2 DISTRIBUTOR ❑ 4P R ✓Ebx if INDIAN EPA IDN MoI TANK's <br /> ❑ 1 GAS STATION ❑3 FARM HER TRUSTVLANDS ION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME( ST,FIRST) PHONE N WITH AREA CODE DAYS.:_NME(UST,FIRST) PHONE N WITH AREA CODE <br /> >v .l 7� <br /> NIGHTS N E(UST,FIRST ONE N WITH AREA CODE NIGHTS: NAME(ITASK FIRS ) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORINATI N & ADDRESS - (MUST BE COMPLETED) <br /> NAMF. CARE OF ADDRESS INFORMATION <br /> MAILING or ST5EET ADDRESS ✓Box to indicate Q PARTNERSHIP Q STATE-AGENCY <br /> L..-, - Q CORPORATION Q LOCAL-AGENCY 13FEDERAL-AGENCY <br /> Q INDIVIDUAL QCOUNTY-AGENCY <br /> CITY NAME P _ STATEZIP C � PHONE N,WITH AREA CODE <br /> A C' <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Q PARTNERSHIP Q STATE-AGENCY <br /> Q CORPORATION Q LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> Q INDIVIDUAL Q COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,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: 1. II. 0 Ill.❑ <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 /> DUU�NC_ V <br /> TYN JURISDICTION M AGENCY R FACILITY ID# M of TANKS at SITE <br /> / 121Lm�J�J O <br /> CURRENT LOON AGENCY FACILITY ID a APPROVED BY NAME PHONE N WITH AREA CODE <br /> J <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT If SUPERVISOR•DI8T ICTC DE BUSINESS PLAN FILED DATE FILE= <br /> YES 0 NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• 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 011'y ' <br /> FORM A(3-2-98) - `/l <br /> %W DATA PROCESSING COPY �+ II <br />