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STATE OF CALIFORMA WATER RESOURCES CONTROL BOARD h`N <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SIT - , FACILITY/SITE, INFORMATION and/or P MIT APPLICATION <br /> JCOMPLETE THIS FORM FOR EACH F ILITY/SITE `^t�•oa�`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ZiLgz <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> f)F <br /> ADDRESS ` /� NEAREST CROSS STREET ✓eawioca, ❑ PARiwEw? ❑ STATE AGENCY <br /> N ❑ C9YGE0.A11ON ❑ LOCAL-AGENCY ❑ fEOEMLAGD0 <br /> N J 1 C3�F!]NIWAL 0 C0uAmr.AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> (13`FO In -�(Ivv CA r a 3 -- ' <br /> TYPE OF BUSINESS: ❑ 2 DISI BUTOR ❑ d PROCESSOR ✓Box it INDIAN EPA ID N <br /> ❑ 1 GASSIATION FARM 5 OTHER RESERVATION or AT THIS SITE <br /> ❑ TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(I-AST,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 S=S i ye CARE OF ADDRESS INFORMATION/ <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME -S I <br /> A CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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. it. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY R FACILITY ID R N of TANKS at SITE <br /> M E= <br /> CURRENT LOCALA NCT FACILITY ID APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> E GE B TRACT a BUPERVISOR-DI8T111CT CODE BU81NE98 PLAN FILED ND ❑ DATE FILED <br /> PERYIT AMOUNT BURCNAROEAYOUNT FEE CODE RECEIPTN BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 <br /> 1FORM A(3-2 <br />