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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '" <br /> FORM `A': a�.� - -F; <br /> UNDERGROUND STORAGE TANK PROGRAM = " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION '°, ,/ e <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE `'�,Foe��"' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE YC ITE N <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Cr <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) V <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bm b+dcaR ❑ PNPNER§IIP 0 SiAiE-AGFN(N <br /> ❑ CONPOMTON 0 LOCALAGENCY 0 FEDERAL-AGBaa <br /> 0 NorvDGu O CGwm ABB+CY <br /> CITY NAME STACODECODE SITE PHONE#,WITH AREA CODE <br /> TYPE OF USINESS: ❑p DISTRIBUTOR ❑4 PROCE6SOR ✓Box if INDIAN EPA ID x 5 <br /> 1 GAS STATION 3 FARM 5 OTHER RESERVATION or p of TANK'p <br /> ❑ ❑ TRUSTLANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIM RY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & DDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED R BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR 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 If AGENCY# FACILITY ID# #of TANKS at SITE <br /> / % L)_ 1? 101010101 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE <br /> I <br /> PERMIT NUMBE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACTp 0 SUPERVISOR-DISTRICT CODE BUSINESSPLAN FILED DATE FILED(/ y/l <br /> gYES NO a T / <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: 1, i <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLFS'THIS IS A CHANGE OF SITE INFORMATION ONLY., 1�V <br /> FORMA(3-2-88) <br /> QJO?�, \ <br /> ' —q Jl DATA PROCESSING COPY <br />