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SE r'.V.ie� 'Af <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIO lot 10 <br /> �'dlIFOR�\\P <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION TLV CLOSED SITE � <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q0 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAM CARE OF ADDRESS INFORMATION <br /> ADDRESS Q/ NEAREST CROSS STREET ✓&xM nOipk ❑ PARTNERSHIP STAIE-AGENCY <br /> 3/ / / I ❑ mGPOPAnGx ❑ CGCNacGEN EOBULacFac <br /> C.� h/ ❑ INGmouN ❑ COUNTY AGENCY <br /> CITY NAME / <br /> STAT ZIP CODE SITE PHONE M,WIlLi A7A COD <br /> TYPE OF BUSINESS: N EPA ID If Z[//{ TANK <br /> ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN p of TANK'a <br /> 5 OTHER RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION ❑3 FARM ❑ TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicate 11 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <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#,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 NO <br /> AND BILLING: I. ❑ II. El 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 S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# If of TANKS of SITE <br /> = = Zd / / Do <br /> ff2nj <br /> FACILITY ID p APPRLA PHONE p WITH AREA CODE <br /> P,117 3 /PERMIT APPROVAL DATE ON DATENSUS TRACT p SUPERR-DISTRICT CODEFILED DATEFILED/NO ❑ NI'GRMIT AMOUNT SURCHARGE AMOUNT RECEIPT a <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 ONL�5 <br /> FORM A(3-2-88) • <br /> DATA PROCESSING COPY <br />