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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM ten' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH AGILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P NENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O. <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) tTT <br /> FACILITY/rE NNNpppME f� <br /> � � Ol✓;O CARE OF ADDRESS INFORMATION <br /> ADDRESS •' !/Ar�t'GBz <br /> 0 FVT <br /> NEAREST CROSS STREET ✓gapnp�l� NBDW 11 PATE AGENCY5 CIT <br /> - ElCONFUTATION ❑ LOGLL, NCI 13 FEDEWAGE10 <br /> Y NAME ❑ INaVIWAI ❑ C MIY.AGENC/ <br /> STATE ZIP CODE SITE PHONE p,WITH AREA CODE_� <br /> (//'7 <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 P ✓Box it INDIAN EPA ID 4 I <br /> ❑ 1 GAS STATION ❑3 FARM OTHER TRUSTTVATION LANDS OF ❑ F of <br /> AT THHISIS SI7E (� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE TO WITH CODE DAYS NAME NAME LA T,FIRST) PHONEWITH qR COD <br /> 7 6p V �6s� <br /> NIGHTS: NAME ILAST,FIRST) IS <br /> PHONE WITH AREA CODE NIGHTS: N E ILA ,FI ST) PHONE M WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION ,) <br /> MAILING or STREET ADDRESS ✓Box Lo inpicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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 md,cale Cl PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> El INDIVIDUAL ClCOUNTY-AGENCYCITY 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. ❑ 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 N JURISDICTION K AGENCY A FACILITY ID M X of TANKS BI SITE <br /> I I I /F� 3 3 d <br /> CURRENT LOCAL AGENCY FACILITY ID NAPPROVED BY NAME PHONE 1 WITH AREA CODE <br /> PERMIT NUMBER V�dJ• PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> [CHECK <br /> CATION CODE CENSUS TRACT SUPERVISOR-DISTRIC CODE BUSINESS PLAN FILED DATE FILED <br /> 0 (� YES NO /��Z /l <br /> F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT F BY: <br /> ��S l <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 <br /> FO A(3-2-881 <br /> / <br /> 3 / <br /> r,,, DATA PROCESSING COPY <br />