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STATE OF CALIFORNhk' WATT R RESOURCES CONTROL BOARD ="`.. <br /> FORM 'A': �� <br /> UNDERGROUND STORAGE TANK PROGRAM = ` Mo <br /> SITE FACILITY/SITE, INFORMA PION and/or PERMIT APPLICATION , <br /> COMPLETE THIS'. ORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEWT'kRM1T ❑ 3 RENEWAL PEI MT ❑ 5 CHANGE OF INFORMATION 7PERMANENT�L SITE I-.a <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ q AMENDED PE AIT ❑6 TEMPORARY SITE CLOSURE I �/ <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MI IST BE COMPLETED) LD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Ln <br /> ,erg 4- <br /> ADDRESS /) NEAREST CROSS STREET ✓3m I0s0We 0 PNITNE%W 0 STATE AGENCY <br /> V y A 0 CO WORATIDN 0 LOX AGENCY 0 FEDEW AGENCY <br /> 11INDVIDIAI 0 CANT(AGENCY CRY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> iIV TJ} CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ q PROCESSOR ✓Box if INDIAN EPA ID N <br /> ❑ I GAS STATION ❑3 FARM ❑5 OTHER <br /> RESERVATION <br /> ❑ of TANK'S <br /> AT THIS SITE `�-- <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH ARE CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS NAME(LAST,FIRST) PHONE N WITH ARE: CODE NIGHTS. NAME(LAST FIRSTI PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING W STREET ADDRESS ✓BoN W,ftcale ❑ PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (M JST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING m STREET ADDRESS ✓Sox to,nd¢ale ❑ PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ 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 ABOVE ADDRESS SHOULD BEL ED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ it. ❑ tll.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PE ?JURY,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 N JURISDICTION <br /> 0 AGENCY N FACILITY ID F N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> -Zr" ✓'-''/-�'/,L' <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT -ODE BUSINESS PLAN FILED DATE FI D <br /> YES NO ❑ L7 z - <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <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 /> FORMA(3-2-IM) �y <br /> DATA PI :)CESSING COPY <br /> i <br />