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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD a <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM aL^ Z <br /> m, ' .° to <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,. <br /> ffMARK <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> NLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITEEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE (D <br /> N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) O <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> d Seri ✓e+-L -FurvnS rnG,R <br /> ADDRESS (j NEAREST CROSS STREET ✓fA�0MPA71m � i���, O F7ATE ACY <br /> GENB+cr <br /> Q , CA-. J ❑ ADNOM ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N a 01 TANICL /1 <br /> RESERVATION or ❑ /)J � ATTHISSRE (� <br /> ❑ I GASSTATION ❑ 3FARM �S OTHER TRUST LANDS / A' <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 /> ILto Cao4 a - loa D <br /> NIGHTS: NAME(LAST, IRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> e COR y(oa - 37(0 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FNAM CARE OF ADDRESS INFORMATION <br /> IUNGo BEET AQQ\Q�RESB ,,/�J (� m✓/d�ox to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> JO k/ �„ fer J w CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 911 _7 / ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE O PHONE N,WITH AREA CODE <br /> 7 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> a er <br /> MAILING or STREET ADDRESS V(7 Box to intlicate ElPARTNERSHIP C3STATE-AGENCY <br /> CORPORATION ❑ 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. ❑ I. ❑ 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 R JURISDICTION N AGENCY R FACILITY ID a R of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE a WITH AREA CODE <br /> PERMIT NUM R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 YES NO a <br /> CHECNa 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 ONLY. <br /> FORM A(3-2-85) _ - <br /> w..-: DATA PROCESSING COPY Iia <br />