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STATE OF CALIFORNIR- WATER RESOURCES CONTROI-BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACHFACILITYISITE "'•�^"'" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 1 Y CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME _ CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓BwbYHoe 0 PAWNBDV 0 STATE AGDO <br /> ❑ DWFORATIQN ❑ LOCAL-AGENCY ❑ Fc')Dk AGENLY <br /> V ❑ NOMWAL ❑ WUNTY.AGENCY <br /> CITU NAME STATE ZIP CODE SITE P O M.WITH AREA CODE <br /> / CA 9 7� (� <br /> TYPE OF BUSINESS'. ❑2 DISTRIBUTOR ❑ 1 PROCESSOR ✓BOW I(INDIAN EPA ID NRESEM 0/TANMa /l <br /> ❑ 1 GAS STATION [-] 3 FARM ❑ 5 OTHER TRUSTYLAND$ATION dT 1:1AT 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 /> NIGHTS'. NAME(LAST,FIRST) 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 w STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 11 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 to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 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 VISION ABOVE ADDRBSS 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY* FACILITY ID R N of TANKS at SITE <br /> 571 = = I I I zA / � / <br /> CURRENT LOCAL AGENCY FACT N APPROVED BY NAME PHONE S WITH AREA CODE <br /> diary .Z 33 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMfT EXPIRATION DATE <br /> LOCATION ODE CENWSTM N 8UPERVI80R ISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Z Z YES ❑ No <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY /J <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 /> UIjbAOt' <br />