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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM A% UNDERGROUND STORAGE TANK PROGRAM V o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m I o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT fjp5'CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDSITE I"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 61-S a) <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) (7) <br /> O <br /> FACILITY/SIT NAMECARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ft I.wed, 0 PARNESHIP 0 STATE-AGDO <br /> 0 COMPOMBON 0 LOCAL-AGENCY 0 FEDEWIAGDO <br /> 0 INDNIDU& 0 IXIUN11'-Marx <br /> CITY NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE <br /> N CA S20S— <br /> TYPE OF BUSINESS ❑ DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ ❑ TRUSTATION LANDS <br /> or 1:1 <br /> ATTNIS SITE <br /> I GAS BTATION 3 FARM 5 OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAM / CARE OF ADDRESS INFORMATION <br /> Y aS .l <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE H.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> W <br /> Cr <br /> MAILING or STREET ADDRESS ✓Be.to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,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. vII. ❑ 111.❑ <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 R JURISDICTION R AGENCY M FACILITY ID R N of TANKS at SITE <br /> = = (d Od <br /> CURRENT LOCAL AGENCY FACILITYLP If APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS T�CT• SUPERVISOR-DISTRCODE BUSINES;P SN FILED NO ❑ DA FLED n <br /> CHE K♦ PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• BY: C <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(3-2-88) <br /> DATA PROCESSING COPY <br />