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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD y�x <br /> f <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ITY/SITE `'•���e=" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 IPEROSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 4001 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Sa vk oA (nl L ww b <br /> ADDRESS / NEAREST CROSS STREET ✓Smbirduk D PAIMERSHIP D STATE AGM <br /> 4 s F. I 1 = ST 5 o NDIVQJk_UMN]RATIM 0 LOCA_ ❑ FMR AGEN Y <br /> CY <br /> CITU NAME STATCA Z1�E �� SITE H NE p,WITHAREA CODE <br /> TYPE OF BUSINESS' ❑ 2 DISTRIBUTOR ❑ 1 P ESSOR /B <br /> Box INDIAN EPA ID N 2 al �(�/F31 <br /> RESERVATION or N of TANK'F <br /> E] I GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PPEE�RSS{/O/JN(PRIIMPARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NA LA U�S O WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE k WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Z <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATEAGENCY <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 /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ox STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> D INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION M AGENCY M FACILITY ID N S of TANKS at SITE <br /> � yI I I 13 &�10 ° <br /> CURRENT LOCAL AGENCY FACILITY ID J / APPROVED BY NAME PHONE F WITH AREA CODE <br /> 57IN J� 4S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> P <br /> DE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED y <br /> � V(/ YES E] NO [] 9_PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT AT 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 ) <br /> 1 ,� ah <br />