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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 'F <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM 7 �o <br /> Sl FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 4— COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 P/ TLV CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT 1:14 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 16 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> �r p <br /> ADDRESS NEAREST CROSS STgEET ✓BPbigide Cl W PARINRI 0 STATE AGENCY <br /> I'DCGPO 01 Cl LOCAL-AGENCY 0 FEDE14-AGE10 <br /> ❑ IWMWAL 0 0"TV AGENCY <br /> CITY NAME Ar <br /> STATE ZIP ODE �SITE�� J� <br /> PHONE At, <br /> CODE aaigLo <br /> TYPE OF BUSINESS ❑2 IN IBUTOfl ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> of TANK's <br /> Ell GAS STATION FARM ❑ SOTHEfl TRUSTVLANDS ATIONur ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> d0�1 333 a I? <br /> NIGHTS: NAME(LAST,F ST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STRERf ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME S r CARE OF ADDRESS INFORMATION <br /> MAILING or STRE&ADDRESS ✓Bon to inflate 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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: 1. ❑ 11. ❑ 111. ❑ <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 E JURISDICTION If AGENCY N FACILI Oi •of TANKS SI SITE <br /> 3 D I I I I D <br /> CURRENT LOCALTRIZINCY FACILITY 10 N APPROVED BY NAME PHONE F WITH AREA CODE <br /> Jai 3 CD <br /> PERM) AL DATE PERMIT EXPIRATION DATE <br /> WOCA"OMCODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE F LED <br /> 19.1 4YES NO ❑PERMITAMOUNT 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 /> ' <br /> FORM <br /> `)A(3-2-SB) S <br />