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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> rF r <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM °o <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -m to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWAL CHANGEOFINFORMA710N ❑ 7 PERM LY CLOSED SITE I-+ <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 80 <br /> N <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) —4 <br /> FACILITY/SITE CARE OF ADDRESS INFORMATION <br /> AD44,E441 S F/'[' /�•/•p_ NEAREST CROSS STREET ✓embalm¢ ❑ PAMNEW ❑ STATE AGBILY <br /> ❑ �R9PAilON 1:1LGCALA(iM 0 FFEDUK-AGDO <br /> G L4yBE(VIWAL 0 COUMAGDILY <br /> STATE ZIP OCDE ^ SITE PHONE N,WITH AREA CODE <br /> M1Y❑/-22 DISTRIBUTOR ❑4 PROCESSOR ✓Box 0INDIAN EPA CA <br /> TYPE OF BUSINESS. _ '# <br /> RESERVATION or R of TANKAT THIS SITE j <br /> ❑ T GAS STATION ❑3 FARM OTHHi TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREACODEDAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Flai <br /> NIGHTS: NAME(Loi <br /> F BT) PHONE WITH AREA CODE NI HTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Sam►^-e- <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME h ` CARE OF ADDRESS INFORMATION <br /> MAILINGor STREETADDRESS ✓Box to indicate 13 <br /> PARTNERSHIP 0 STATE-AGENCY <br /> a / � 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> C� v 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �S <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <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: 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 /> APPUCANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY# FACILITY ID R K of TANKS at SITE <br /> © � 01EDO <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 2 3 YES NO ❑ 5/ <br /> 3d Fj <br /> CHECK# PERMIT AMOUNT SURC ARGEAMOUNT 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 /> FORM A(3-2-W) / <br /> y` DATA PROCESSING COPY <br />