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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> SITE UNDERGROUND STORAGE TANK PROGRAM =eco <br /> �— FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION S�r <br /> I COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEWPERMIT 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION PE MAN SED SITE )—► <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 5V <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) �! <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION N <br /> ADDRESS NEAREST CROSS STREET ✓Bw N vdfAl 0 PARTNENSIP ❑ SMTEAGDO <br /> 0 IXIRPDMTDN 0 LOCAL AGENCY 0 FEOENLAGENLY <br /> ❑ WOIVIDJN ❑ NIINry#GENCY <br /> CITY NAME �- STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: E] 2 DISTRIBUTOR ❑4 PROCESSOR ✓13M if INDIAN EPA ID N <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER ITRUSTLANDSRESERVATION w ❑ B of TANK') ^ <br /> AT THIS S..c a— <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(UST,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 /> MAILING w STREET ADDRESS ✓Box to iMicele 0 PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING w STREET ADDRESS ✓Box W mdicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE p,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: 1. ❑ 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 Y JURISDICTION# AGENCY# FACILITY ID R M of TANKS at SITE <br /> 12-1 ,31 V10 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE I WITH AREA CODE <br /> 70 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT/ SUPERVISOR• 1!D'ItICT CODE BUSINESS PLAN FILED DATE Fl D <br /> YES ❑ NO ' <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> FORM A(3-2-88) <br /> D;LTA PROCESSING COPY '� <br />