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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> 2 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 10 <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ,CHANGE OF INFORMATION ❑ 7 PERMANENI=LOSED SITE IV <br /> ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE � <br /> I.FACILITY/SITE INFORMATION &ADDRESS -(MUST BE COMPLETED) <br /> FACILI /SITENAM <br /> CARE OF ADDRESS INFORMATION <br /> Ell If <br /> ADDRESS I 'TI NEAREST CROSS STREET ✓ roirtic* ❑ PARTNERSHIP ❑ STATE-AG <br /> SN'CY <br /> 7JRPOR9iDN ❑ LOCH-AGENCY ❑ FEOEMLAGBICI <br /> ❑ INGIVIGIlAL ❑ (gI1H1V.pGENG1' <br /> CITY NAME STATE SITE PHONE N,WITH AREA CODE <br /> 1 IF CODE <br /> CA `f-D ao <br /> TYPE OF BUSINESS: 2DISTRIBUTOR 4 SSOR ✓ <br /> ❑ Box if INDIAN EPA ID N <br /> ❑ 1 GAS STATION ❑3 FARM OTHER RESERVATION or ❑ N of TANIC <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,RBST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WTTHAREA CODE <br /> II. PROPERTY OWNER INFORMAT ON & 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 & ADDR SS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 13 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRE S <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD B SED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P JURY,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 R JURISDICTION K AGENCY N FACILITY ID N R of TANKS at SITE <br /> U_al 10o / (:5) 1 / I(F <br /> CURRENT L LAGCNCY FAC YID, WITH BY NAME PHONE,WH AREA CODE <br /> e <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> DE CENSUS TRA SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a 3 , YES NO —a (DN <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOWANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> , F,1g1RMA(3-2-88) <br /> \ �,' / I. r�.-�� b, DATA PROCESSING COPY <br />