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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE O <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> ••W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS O/ NEAREST CHO$$$���ggg7��ARR)TlQnr si ✓Bm biixNal¢ ❑ PARiNENSIP Cl STAiEAGENLY <br /> _ f�gPOH4ilON ❑ 10CA4AGENC! ❑ FE3EAALAGENLY <br /> NDVIWAE ❑ CDW11Y-AGENCY <br /> CITU NAME STATE ZIP CODE SITE PHONE M,WITH AREA CODE <br /> e5 ca �Oi• CA <br /> TYPE USINESS: ❑2 DISTRIBUTOR ❑4 ESSOR ✓Box if INDIAN EPA ID # A�l� #of TANK's <br /> RESERVATION or a`(�_7 ATTHIS SITE <br /> I GASSTATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE _ <br /> ✓e of Aa v-ei- S�"L <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(I-AST,FIRST) PHONE It WITH AREA CODE <br /> C.4aver, a✓e l{ {, <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓ xto lodcate D PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION Cl LOCAL-AGENCY D FEDERALAGENCY <br /> ✓n� D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓ x to indicate 1:1PARTNERSHIP D STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. 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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY#. FACILITY ID# #of TANKS at SITE <br /> 3 9 o o a y v v1 01 0 <br /> RR NT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> P O ROYAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a 3 0 3 tr:2l`P YES ❑ NO ❑ <br /> CHEC PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: PT YO <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 111 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) `( <br /> DATA PROCESSING COPY <br />