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Ole Ai:Aimp <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> FMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENT Y CLOSED SITE <br /> TEM ❑2 INTERIM PERMIT < AMENDED PERMIT <br /> ❑ ❑6 TEMPORARY SITE CLOSURE O z <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Goo' F TRE r <br /> AW <br /> ADDRESS / NEAREST CROSS STREET ✓Bw loneraa ❑ NNiMR➢IIv IJ SiAiEAGENCt N <br /> /I I'lly ❑ WWWOIUnON ❑ IDDAL.AGENO/ Cl FEMME AGEN <br /> CITY NAME ❑ INDIVIDUAL 0 DOUNMAGENCY w <br /> STATE ZIP CODE SITE PHONE x,WITH AREA CODE N <br /> CA <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑A PROCESSOR I ✓Box if INDIAN EPA ID N <br /> ❑ I GAS STATION [:]3 FARM ❑5 OTHER TRUSTYLANDS ATION or ❑ N of <br /> AT THHISIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS. NAME(EAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(EAST,FIRST) PHONE N WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓BON Io imcale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION O LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE DECODE PHONE k,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ) ✓Ito.10'"cal. 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> _ ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M.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: E ❑ 11. ❑ 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 B JURISDICTION N AGENCY N FACILITY ID N M of TANKS at SITE <br /> IM = = oao7 000 <br /> CURRENT LOCAL AGENCY FACILITY IO I APPROVED BY NAMjf PHONE R WITH AREA CODE <br /> �D y� <br /> PFo.-ITNUMBER PERMIT APPROVAL DATE PERMIE <br /> N DATE <br /> LOCATIONCODE CENSUS TRACTa SUPERVISOR-DISTRICT CODE BUSINED DATE FILED <br /> NOCHECK$ "RUM AMOUNT SURCHARGE AMOUNT FEE CODERECEIPT N BY: <br /> I <br /> JTHIS FORM MUST BE ACCOMPANIED BY AT LEAS' 'OR MORE TANK PERMIT FORM 'B`APPIICATION(S), UP' �S THIS IS A CHANGE OF SITE INFORMATION ON i <br />