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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> a <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F—] 1 NEW PERMIT F—] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CI-OCED SITE N 1 <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE s o , w <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME TION <br /> CARE OF ADDRESS INFO MA <br /> n /nom <br /> ADDRESS NEAREST CROSS STRE ✓awa feme ❑ PARTNEMIP ❑ STATEAGENCY <br /> ❑ RATION ❑ LOCAL-AGENCY ❑ FEDERALAGEND <br /> �NDrvmUAl ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> Loc9 A CA 12y o <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or AT <br /> HIS SI <br /> ❑ I GAS STATION ❑ 3 FARM �THER TRUST LANDS ❑ AT TRIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS', NAME(LAST,F RST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME ^ _ CARE OF ADDRESS INFORMATION <br /> 1( IV 1 (1,(,IGL.,Q �-- Ute"G A�-- <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 3q I y CL./\ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATt ZIP, ODE PHONE N,WITH AREA CODE <br /> Ccn U) I I_Q V- <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5 Q c..o <br /> MAILING or STREET ADDRESS ✓Box toindidate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ 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 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 M JURISDICTION S AGENCY M FACILITY ID R K of TANKS at SITE <br /> 31 1 d o9- 0000 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION E CENSUS TRACTO SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED NO ❑ D E FILED <br /> YES <br /> CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M ST. <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 ONLI� <br /> DATA PROCESSING COPY �trf-, <br />