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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM mo <br /> S FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 41`5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDSITE O <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> D� <br /> ADDRESS /I .— NEAREST GROSS STREET ✓HmloadoiW El PARTNERSHIP ❑ STATE AGENCY w' <br /> 5 ❑ CORKRATION ❑ IOCLL AGENCY ❑ F L AGENCY <br /> ElINDNIDUAL ElCWNIYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> �b Cu CA YD (26433V 3.3 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ /P ESSOR ✓Box if INDIAN EPA ID p If <br /> RESERVATION dr AT <br /> HIS SI <br /> ❑ 1 GAS STATION [:]3 FARMC. <br /> OTHER TRUST LANDS El <br /> TIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: ME ST FIRST) PHONE p WITH AREA CODE GAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> <ao9 33 Y- oa CUA' ;s ao 9 33N-/Oa <br /> NIGHTS: NAME(LAST,FIRST) I PHONE#WITH AREA CODE NIGHTS: NAME(IA FIRST) PHONE#WITH AREA CODE <br /> Q�vl✓ C SQ.✓✓ e� <br /> II. 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 /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK 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 /> CITY NAME TATE 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 LE NOTIFICATION AND BILLING: I. ❑ 11. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TH EST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY# FACILITY ID N M of TANKS at SITE <br /> CURRE LOCAL AGENCY FACILITY IO_jff, APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION DE CENSUS TRACT,( O SUPERVISOR-DISTRICT BUSINESS PLAN FILED DATE FILED <br /> _/If Qv YES ❑ NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST ftt OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> ' (FORM P(3-2/-S8) \ <br /> DATA PROCESSING COPY <br />