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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM a <br /> SITE _ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM OSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> F LI E NAM CARE F ADDRES INFOR TION, <br /> Of ( <br /> ADDRESS NgAIREST CROS STtElFf PARINENSHIP 0 STATE AGDO <br /> U l C`I lV 11COFFGICI uAAi� °o m AGR Rom l-cENa <br /> CITY N E STATE ZIP CODfi� SITE PHNE N.WITH AREA CODE <br /> cA S �b 31-31 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> 1 GAS STATION �y 3 FARM ❑ 5 OTHER RESERVATION or AT THIS SITE <br /> ❑ I vl TRUST LANDS ❑ J\; <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> D N E(LAST,FIRST) P ONE N WITH AREA CODE DAYS AME(LAST,FIRST) PHOPE ft WITH AREA CODE <br /> t �t3t -31 A <br /> NIGHTS AME LAST.FIRST) NE#WITH AREA CODE NIGjA NAME(LAST,FIRST) PI-Opt N WITH AREA CODE <br /> II. PROPER Y OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAM • CARE ORES FORMATION / ( <br /> CA_ <br /> MAIG or$TREEiADDR S ✓Box to indicate PARTNE P 0 STATE-AGENCY <br /> 1/lT S <br /> CORPORATION LOCAL-A CV EDER- AL,fGENCY <br /> 6 0 INDIVIDUAL 0 COUNTY-AGENCY =K <br /> CITY NA• STAT ZIP C� P NE If,WITH AREA DE �� <br /> CSA Q/ I <br /> III. TANK OWN INFORMATION &ADDRESS - (MUST BE COMPLETED) i <br /> NAME CARE OF ADDRESS INFORMATION <br /> f <br /> MAILING or S-FRIEET ADDRESS ✓Box to indicate Cl PARTNERSHIP 0 STATE AGENCY - <br /> ❑ CORPORATION 0 LOCAL-AGENCY Cl 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: I. ❑ if. V 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 R AGENCYIN FACILITY ID N R of TANKS at SITE <br /> ,= = = I Lo I e 000 <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAJAE PHONE M WITH AREA CODE <br /> PERMI NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICr CODE BUSINESS PLAN FILED DATE FI D <br /> YES NO d 2 t <br /> CHEC • PERMIT AMOUNT I SURCHARGE AMOUNT FEE CODE RECEIPT k BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CIUNGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> '11"1 DATA PROCESSING COPY � <br />