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9AH O.F Nf <br /> STATE OF CALIFORNIA-- WATER RESOURCES CONTROL`aOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ,5 CHANGE OF INFORMATION ❑ 7 PER TLY CLOSED SITE <br /> MARK ONLY ❑ 6 TEMPORARY SITE CLOSURE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑< AMENDED PERMIT <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> n G CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME_ 1-C - A /C ^A �x „ u <br /> G ��J I C/ a(� NEAREST CROSS STREET '/BMW tET1 ❑ PAK-Namw ❑ STATE-AGENIX <br /> ADDRESS (' V L (��E ❑ WIWIDUAL ! ❑ lOCll#GENLY ❑ ROEIUI AGBICY <br /> ? ❑ INDNIWAI D Lock AGENCI <br /> STATCA ZIP CODE ^� SITE PHONE N.WITH AREA CODE <br /> CITY NAME 7 / <br /> TYPE OF BUSINESS 2 DISTRIBUTOR ❑ A PROCESSOR ✓Box if INDIAN EPA 10 N #of TAMC# <br /> RESERVATION or AT THIS SITE <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP FADE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FNAME a STREET ADDRESS 7 ✓Boz to inEicani ❑ PARTNERSHIP ❑ STATE-AGENCY❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCYD INDIVIDUAL D COUNTY-AGENCY <br /> STATE ZIP CODE PHONE M,WITH AREA CODEME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ASOVS ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ IIL❑ <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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION R AGENCY M FACILITY ID R It of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID Ni� yl YY�� <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> N <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVI R-DISTRICT ODE BUSINESS PLAN FILED DATE FILED <br /> _Z <br /> YES NO �� <br /> CHECK# PERMIT MOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Br� <br /> TMS FOR UST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA <br /> PERMIT NUMBER �J PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> C1MCK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# �py � <br /> FORM B(S-T9­B6) THIS FORM MUST BE ACCOMPANIEtreY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />