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oe <br /> STATE OF CALIFORNIA7 WATER RESOURCES CONTROL BOARD <br /> WP• A <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE ACILITY/SITE, INFORMATION and/or PE IT APPLICATION <br /> f/ d' 10 <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE c"1OP"'P <br /> MARK ONLY EW PERMIT ❑ 3 RENEWAL PERMIT HANGE OF INFORMATION ❑7 PUUANENTL7 CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE OI cn <br /> W <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) V <br /> FACILITY/SITE NAME /.f,�' CARE OF ADDRESS INFORMATION <br /> N v" <br /> ADDRESS NEAREST CROSS STREET ✓B.O'du, D PARTNERSHIP D STATEAGDOY <br /> /275-0 P148 RoN ❑ CODRA110N D LOCALAGELAGENCP ❑ FEDERAL-AGM <br /> 0 INOMOUAL D COUNTYENCV <br /> CITY NAME �" M STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> / A rI_l CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBLROR ❑4 PROCESSOR I ✓Box d INDIAd EPA ID N If M TANK's <br /> ❑ 1 GAS STATION ❑3 FARM ❑ <br /> 5 OTHER RESERTRUSTYLANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHON�K WITH AREA CODE <br /> S/DQ <br /> NIGHTS NAME(LAST,FIRST) I PHONE k WITH AREA CODE I NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz 10 mclicete 0 PARTNERSHIP D STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHO HE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME S_-'" - CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box to inGicete 0 PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION Cl LOCAL-AGENCY FEDERAL-AGENCY <br /> 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE .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. ❑ 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# FACILITY ID R R of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> 4/;-- <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODED CENSUS TRACTNQ� SUPERVISOR-�D7IB/ERIC CODE BUSINESS PUN FILED DATE FILED <br /> 3 ✓ V !/ YES � NO �.�4ON <br /> CHECKN PERMIT AMOUNT SURCHARGE ANOU T FEE CODE RECEIPTN BY:TMS FORM MUST BE ACCOMPANIED BYATLEASTM)OR MORETANKPERMIT FORM 'B'APPLICATION(S), UNLESSTHIS IS A CHANGE OF SITE INFORMAT <br /> 4FO M A(3-2-8R) <br /> _ DATA PROCESSING COPY <br />