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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 HE PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEMINTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSUREEdit[O <br /> I. FACILITY/SITE INFORMATIONS ADDRESS— (MUST BE COMPLETED) jq <br /> FACILITY/SITE NAME CARP OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓NmmaKse D PANINENSV D STATEAGENLY <br /> ❑ WHIMTKIN ❑ LDC AGBICY ❑ FEMRk AGDCY <br /> CfJL� L�/ l ❑ NIwouk ❑ COMIY+IGENLY <br /> CITY NAME STATE Z.IP CODE SITE PHONE N.WITH AREA CODE <br /> 1 CA <br /> TYPE OF BUSINESS' ❑Z DISiRlBllf ❑/PROCESSOR ✓Box it INDIAN EPA IO a <br /> RESERVATION or Nal TANK'S <br /> ❑ I GAS STAT04 ❑ G FNM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(UST,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 N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boa to iwi ate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL AGENCY <br /> _ ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING ar STREET ADDRESS ✓BOX to lwq mle D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D 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: L ❑ 11. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE �\L <br /> LOCAL AGENCY USE ONLY c! <br /> COUNTY N JURISDICTION N AGENCY i FACILITY ID 0 Nal TAN SI <br /> 3 �' = - a <br /> CURRENT LOCAL AGENCY FACILITY 10 N / APPROVED BY NAME PHONE• TN AREA CODE <br /> 13 C (!(, <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION COOS CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED G <br /> YES NO El O <br /> CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTS BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST" 'OR MORE TANK PERMIT FORM 'B' APPLICATIONISI, UHL FSS THIS IS A CHANGE OF SITE INFORMATION ONLY. � <br /> FONM A 111 SSI <br />