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STATE OF CALIFORWA WATER RESOURCES CONTROL BOARD <br /> a <br /> FORM `A': <br /> SITE UNDERGROUND STORAGE TANK PROGRAMFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 10 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OFINFORMATION <br /> ONE ITEM 7 PERMANENTLY CLOSED SITE I-& <br /> ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 50 ­4 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) v W <br /> FACILITY/SITE NAME ` <br /> WCARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> lO NEAREST CROSS STREET ✓Bmi 10 WXiCA10 ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPWTI ❑ LOCk AGDO ❑ FEOEPAL.AGENCY <br /> CITY NAME ❑ INDMIIUAL ❑ CWNIY AGENCY <br /> C I STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> TYPE OF BUSINESS' J cM. CA <br /> ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box N INDIAN EPA ID IT <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTYLANDS oT ❑ N o1 <br /> AT THIS IS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE IT WITH ARTA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box W,i d,cate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 1) COUNTY-AGENCYCITU NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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 IPRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY# FACILITY ID# #o1 TANKS at SITE <br /> ® ( c �f U 1 o <br /> CURRENT LOCAL AGENCY FACILITY IDN <br /> S7oC K (�lI I <br /> APPROVED BY NAME PMONEN WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> E <br /> CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE IUD <br /> �,� <4 YES ❑ NO �� eA <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST IV 'MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLF"^THIS IS A CHANGE OF SITE INFORMATION ON <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY `S <br />