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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> SE'iu��i�•�f <br /> ur4 SA <br /> FORM A': N <br /> UNDERGROUND STORAGE TANK PROGRAM =" me <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 621 C0 COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLYF__] I NEW PERMIT F__] 3 RENEWALPERMIT S CHANGE OF INFORMATION Ll7 PERMANENTLY CLOSED SITE <br /> O <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Z <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 10 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ,aOai�LL <br /> R C S <br /> ADDRESS NEAREST CROSS STREET %/Box in ❑ PATTNEASNIP ❑ STATE AGENCY N <br /> 2 7�/i1 x /. O. ❑ CORPORATION Cl LOCAL ❑ FEDERAL AGENCY (J� <br /> J T(/ V/1/((� I�RORIDUAL ❑ COUNTY AGENCY r <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> C��/✓ CA 00 <br /> TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 4 PR OR ✓Box if INDIAN EPA ID 4 <br /> RESERVATION or /� #of TANK's <br /> [:jT GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ �/�-r/ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(IAST,FIRST) PHONE p WITH AREA CODE <br /> ow. L /9 /Y zo9 Y3f- /tee// /� ur IO <br /> NIGHTS. NAME(LAST FIRS PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> l <br /> Ti <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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 Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION R AGENCY# FACILITY ID# #of TANKS at SITE <br /> U S to I O I U <br /> CURRENT LOCAL A NCV FACILITY IDN APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN B <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(3-2-11) - <br /> 5 %I( DATA PROCESSING COPY n/ <br />