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OF <br /> STATE OF CALIFORNI?r WATER RESOURCES CONTROL'BOARD A\ <br /> uP' �• <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITEX FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "`"�""•" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION 7 PE LY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Z <br /> 10 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACLITY/SITE NAME % CARED A DRESS INFORMATION <br /> ADDRESS fJ\ NEAR ST CROS�SST9EET ✓atexwok ❑ PAAINE&9P ❑ STATEAGENCY N <br /> --__ nn (Y.FL- ❑ CORPONATlan ❑ loco-AGBtLY E DwA cr <br /> S• "Ig V� ❑ INDNIDDAI ❑ TAUNiKAGENCY W <br /> CITY NAME STATE ,/ SITE PHONE#.WITH AREA CODE P. <br /> /-49/ ZI O/ CA z, v _r 2i <br /> TYPEOFBUSINESS ❑ 2DISTRIBUTOR 04,PPXESSOR ✓Box S INDIAN EPA ID N #o1 TANK's AAA <br /> ❑ i GAS STATION ❑ 3 FARM OTHER RESERLANDSVATION or ❑ ATTHIS SITE ' <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERISIENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHON #WITH AREA CODE DAYS: NAM)(LAST,FIRST) ONE#WITH AREA CODE <br /> 1 A <br /> NTGRfTS: NAME(LAST,FIRST) H E Irl ITH AREA CODE NIGHTS: IIIA (LAST.FIRST) HONE#WITH AREA CODE <br /> (J A <br /> I <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> N �� • CARE OF DDRESS INFORMATION <br /> MAILING or STREET ADDRESS ;` ox to indicate ❑ PARTNERSHIP 13STATE-AGENCY <br /> ` ❑ CORPORATION ❑ LOCAL-AGENCY ❑ F flAL- ENCU <br /> ElINDIVIDUAL 11COUNTY-AGENCY <br /> CITY AME STATE ZIP CODE PHONE , ITH AREA CODE <br /> I IS140 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CA RE OFUDDRESS INFORMATION <br /> MAIL ,STREET ADO SS ✓ ox to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ EDE L-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU yA STATE ZIP CO E PHONE p WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS S A S <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ ll. Ill.❑ <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# JURISDICTION# AGENCY# FACILITY ID# It OI TANKS at SITE <br /> EHI <br /> d Z DDD <br /> CURRENT LOCAL AGENCY FACILITY 10 11, APPROVED BY NAME PHONE#WITH AREA CODE <br /> 1 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENBUSTMfi`T# 8UPERYI R-DISTRICT CODE BUSINESS PLAN FILED DAT FIUqD <br /> 0_2o41V� VES NO E Q <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: <br /> 1 <br /> THIS FORM M� T BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATIONO <br /> FORM A(3-2-88) <br /> ( DATA PROCESSING COPY <br />