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-------------- <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> b�. <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE �- FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> of <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY LOSED01 <br /> SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT 6 TEMPORARY SITE CLOSURE C" <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) A <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Vlss e <br /> ADDRESS NEAREST CROSS STREET ✓Suw di ilx ❑ PARTNERSHIP ❑ STATE AGENCY <br /> OINRALGNOE �GC 11 FFD A LAGENC <br /> LMWCWN <br /> CITY NAMgg�� STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> /°( I N CA <br /> TYPE OF BUSIN SS ❑ 2 ISTWBUTOR ❑ 4 PROCESSOR -/Box it INDIAN EPA 10 # #of TANK's <br /> RESERVATION or <br /> ❑ I GAS STATION 3 FARM ❑5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME I 1 CARE OF ADDRESS INFORMATION <br /> MAILING or STREEf ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 W indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. V 11. ❑ 111.❑ <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# JURISDICTION# AGENCY# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE Is WITH AREA CODE <br /> - ate <br /> PERMITNUMBER I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE.JILEII <br /> YES NO 9� <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> ORM A(3-2-88) 1 <br /> DATA PROCESSING COPY �`�./ <br />