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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 ! T <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> [— <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> p GNE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r <br /> I N <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> NE REST CROSS STREET ✓Boxm rAlute 0 PARTNERSHIP 0 STATE-AGENCY <br /> ADDRESS 0 CORPORATION 0 LOCAL AGENCY 0 FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNP AGENCY <br /> CITY NAME N STATE ZIP CODE TE P ONE#.WITH AREA CODE <br /> CA 5203 ?tel 5 <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK'N <br /> RESERVATIONor AT THIS SITE <br /> ❑ 1 GAS STATION [—] 3 FARM E: 5 OTHER TRUST LANDS El <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME , ZC <br /> ..J I CE <br /> MAILING or STREET ADDRESS ✓60x to ocP,,.te 0 El ST <br /> PARTNERSHIP ATE-AGENCY <br /> lq , 1 0 CORPORATION El LOCAL AGENCY El FEDERAL AGENCY <br /> I <br /> V ❑ INDIVIDUAL ❑ GOU ,AGENCY <br /> CITU NAME STATE ZIP CODE PHONE WITH AREA CODE <br /> I CA I <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME S <br /> MAILING or STREET ADDRESS ✓Boxmintlicale 0 PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COIiNl,bGENCY <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> ACILIT ID# If of TANKS at SITE <br /> a s o y Cp <br /> CURRENT LOG L AGENCY FACILITY ID N <br /> APPROVED E PHONE N WITH AREA CODE <br /> PERMIT NUMBER I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CEN8USTRAC# SUPERVISOR-2- <br /> ODISTRICT CODE BUSINESSVSNFNO FILED ❑ DATEFl <br /> CHECK N PERMITT AMO IN SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST f OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. n <br /> FORM A Of 2-88) <br /> DATA PROCESSING COPY <br />