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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD J <br /> �Sf'a 'M1f <br /> y A <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM = ' o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> LCOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE I"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FA TYBITE NAME [ CARE OF ADDRESS INFORMATION <br /> J <br /> AD bo kX NEAREST CROSS STREET ✓Bm lo,n W ❑ PARfMRSHP ❑ STATE CRAY <br /> ❑ CDRI TION ❑ L11G1L-ME140 ❑ FWk AGE?&I <br /> ❑ NDMDuu ❑ OWMA,QICY <br /> CITY NME STATE ZIP CODE SITE PHONE M,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR F-14 PROCESSOfl I ✓Box If INDIAN EPA ID k <br /> M of TANS <br /> RESERVATION Of ❑ Y <br /> ❑ I GAS STATION FARM ❑ S OTHER TRUSTLANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE S WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indi .le ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0,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 inEimte ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ 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. ❑ 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 S,SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> �T�COOU�NT(�Y']�# III JURISDICTION If II AGENCY X FACILITY ID N F of TANKS of SITE <br /> IBJ LJ�L.J I s <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> U 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DA FILED <br /> ;1-3 �>-- YES NO 31 <br /> CHECK Y PERMIT AMOUNTSURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> p 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(3-2-88) <br /> W\) �a'/ DATA PROCESSING COPY �„a <br />