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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; to <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT El<cHANGE OF INFORMATION ❑ 7 PE SED SITE CA) <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> *,;2-2(/g-�30 <br /> ADDRESS NEAREST CROSS STREET ✓Boc C PARTNERSHIP ❑ STATE AGENCY <br /> S IP0MT10N C Lom AGENCY D FEDERAL AGBYCY <br /> ❑ INDIVIDUAL D COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SIT ONE p,WITH AREA CODE <br /> CA 5 <br /> TYPE OF SO MESS ❑ 2 DISTRI R ❑ 4 PROCESSOR '/Box if INDIAN EPA ID N Not TANK1 <br /> GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTYLANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS- NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME LA22i 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 /> MAILING or STREET ADDRESS ✓Be.to indicate D PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION C LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL C 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 or STREET ADDRESS ✓Box to Indicate D PARTNERSHIP C STATE-AGENCY <br /> •� J ❑ CORPORATION C LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL C COUNTYAGENCY <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: 1. It. ❑ HL❑ <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 M AGENCY N FACILITY ID N N o1 TANKS at SITE <br /> C)16) 0 Cl o 10 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> �vd <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCIE <br /> ODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES � NO 0 �_�PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-68) <br /> DATA PROCESSING COPY `ya/ <br />