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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '`� 'f <br /> FORM 'A': (%ate- _ - , <br /> UNDERGROUND STORAGE TANK PROGRAM =°' �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•oa�`" <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMA ENTLY CLOSED SITE F+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> C <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMAT/IO'N <br /> u <br /> ADDRESS NEAREST CROSS STREET ✓w0Mim ❑ PARTNSSHIP ElSTATE-AGENCY <br /> L dr ON O LOCAL AGENCY ❑ FEGEIALAGENCI <br /> k/ IEE ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE a.WITH AREA CODE <br /> _S CA `�SaDs C I L <br /> TYPE OF BUSINESS: ❑ 1 DIS R ❑ 4 PROCESSOR ✓Box if INDIAN EPA NO a / <br /> ❑ ❑ TRUSTLANDS <br /> TION or ❑ LL� AT THIS SITE <br /> I GAS STATION FARM 5 OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NA�ME.(LAST.FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> VA9 <br /> NIGHTS: NAME(LAST,FIRST PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME ♦ CA RE OF ADDRESS INFORMATION <br /> bo r6 J �i <br /> MAILING or STREET A DRESS ✓8ox to indlc ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ C TION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> DIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STA ZIP CODE PHONE N,WITH A(i�A CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME �} CARE OF ADDRESS INFORMATION <br /> MAILING or STgEET AD RESS ✓Box m indicate [3 PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CTION ❑ LOCAL-AGENCY 13FEDERAL-AGENCY <br /> IVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PH ONE 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. ❑ II. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION M AGENCY k FACILITY IDM k of TANKS at SITE <br /> 3 % I I I al� 1 04 <br /> p v <br /> CURRENT LOCAI�GF�ICY fA�ITY ID%/ APPROVED BY NAME PHONE A'WITH AREA CODE <br /> PERMIT NUMBER✓`K Ir/�I JTj PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT k SUPERVISOR- ISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO ❑ / <br /> CHECK a PERMIT AMOUNT SURCHARG AMOUNT FEE CODE RECEIPT a <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(3-2-8B) <br /> DATA PROCESSING COPY i <br />