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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM A, z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EACH!r LITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F•a <br /> ONE ITEM ❑p INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 50 W <br /> 00 <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) w <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> �I VR- 0 <br /> ADDRESS NEAREST CROSS STREET ✓ <br /> T ❑ PANE11 STATE AGENCY <br /> COFFOMION ❑ LOAGEN ❑ fEDER4-AGENCY Y <br /> L 1 ❑ u ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE A,WITH AREA CODE <br /> LIDdLx, CA <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a X of TANK'S <br /> RESERVATION or ❑ AT THIS 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 /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to 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 /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M.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. ❑ II. ❑ 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 K JURISDICTION# AGENCY B FACILITY ID AN S of TANKS at SITE <br /> EH = = 0 0 -_) o '4 6 U `0 CU <br /> CURRENT LOCAL AGENCY FACILITY IDX t 1APPROVED BY NAME PHONE V WITH AREA CODE <br /> u Isu <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LLOCATIONCODE CENSUS TRACT0 SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DILEDp YES E] NO ❑ v 0 g fz-- <br /> 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 /> FnRM q(y-2-&g) �J <br /> ,W- / `i DATA PROCESSING COPY `( <br />