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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> 0 <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY 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 /> FACILIj ITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET 8P,to-/ <br /> ✓ mdle D PARTNERSHIPAGENCYFArE <br /> D U:NPoGL�� AGENCEI FEDERAL <br /> AGENCY CO <br /> El INDIVIDUAL EW [ttAGENCY <br /> ry I <br /> CITU NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE W <br /> CA <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK'# <br /> ❑ I GAS STATION ❑ 3 FARM OTHER TRUSTTMATION LANDS or ❑ rw AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ri,q&a, Rud (dpq) qQf-3&10 <br /> NIGHTS'. NAME(V IRRScST.))&, --M1 pp PHONt#WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> UG(� 'y <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ' <br /> S �� O 4 <br /> MAILING or STREET ADDRESS */Box to inaicale 1-1PARTNERSHIPD STATE-AGENCY <br /> / �/ D CORPORATION D LO L-AGENCY D FEDERAL-AGENCY <br /> {O ( 11INDIVIDUAL UNTY-AGENCY <br /> CITY NAME ST41 ZIP CODE PHONE q.WITH AREA CODE <br /> e_iII <br /> 510 ;L <br /> JCIII. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S rima Q.o-� <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE AGENCY <br /> D CORPORATION D LOCALAGENCYD FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTYAGENCY <br /> CITU 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. ❑ it. 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# FACILITY ID At #of TANKS at SITE <br /> d 10 Z) 101011 / <br /> CURRENT LO AL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> A <br /> PERMIT UMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVI OR-DISTRICT CODE BUSINESS PLAN FILED DATE LED <br /> YES NO El <br /> GHEC # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM M,APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-BB) <br /> �" DATA PROCESSING COPY ".0 <br />