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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> A <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM = " A," <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' <br /> rtl <br /> COMPLETE THIS FORM FOR EACH FAC /SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 FgRMAREUjQY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z, <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILOY/SITE NACARE���/O CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSSTREET ✓ Wrfxxa O PARWEASHIP 0 STATE AGP <br /> SEl O LOCAL� 0 N.AGRd <br /> ,4i IN L <br /> CITY NAME .� STATE ZIP ew9 , � ` SITE PHONE N.WITH AREA COO <br /> TYPE OF BUSINESS: ISTRIBUIOR ❑4 PROCESSOR ✓Box if IN AN EPA ID N /QQ 6 ^!/ten If of TANK's <br /> RESERVATION or ❑ AT THIS SITE ?r- <br /> ❑ I GASSTATION 3 FARM ❑ S OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ' z 3i=3 S <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> A _ <br /> MAILING or STREET ADDRESS ✓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 N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> a---s <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVII ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION N AGENCY R FACILISY tO R of TANKS at SITE " <br /> 3 1 MNAME <br /> I d o <br /> CURRENT LOCAL AGENCY-FAMPIRY IF PHONE N WITH AREA CODE <br /> PERMIT NUMBER APPROVAL DATEON DATELOCATION CO E CEN8U8 T11ACT N SUPERV180R-DISTRICT COILED ND DATE FILED/ ��� -3o ICHECK N PERMIT AMOUNT SURCHARGE AMOUNTRECEIPTA BY: C✓ <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(3-2-88) <br /> � I -,-) ?fi <br />