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OF <br /> STATE OF CALIFORNrA WATER RESOURCES CONT46L BOARD <br /> 1 , <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM ' �o <br /> S7MARKONLY <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION <br /> ADDRESS NEA EST CROSS STREET ✓BPmiGrge ❑ PAATNEASHIP D STATE AGM <br /> �j 1n 11C/JPPOIATION 11LOGIMDO ❑ FWA AGBILY <br /> C r e I A ❑ INDIVIDUAL ❑ WUNTY.AGENCY <br /> CITY NAME � / I v, STATE ZIP�� oPHONE X.WITH AREA CODE 9. <br /> q CODE <br /> TYPE OF BUSINESS: ❑ 2'D/ISTRIBUTOR ❑ 4 PROCESSOR ✓Box i1 INDIAN EPA IAID�N <br /> ❑ F " ❑ TRUST LANDS A ON of ❑ I ✓x' AT THIS SITE <br /> 1 GAB STATION FARM 5OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE IT WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ 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 /> S cPi� a.s / <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. IL ❑ 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 k JURISDICTION R AGENCY R FACILITY ID R 0 of TANKS N SITE <br /> 3 �] D 101 `f 2- 05 OBD (0 <br /> CURRENT LOCAL AGENC FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> EL <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> [CHECK <br /> CA N DE CENSUS TRACT N SUPERVISOR-111 ICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 l YES NO p7 <br /> # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS 15 A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> /'\2_� <br />