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STATE OF CALIFORNIA5 P�:uoF'r� <br /> WATER RESOURCES CONTROL BOARD /:• �� '.F <br /> FORM `A': - ' <br /> UNDERGROUND STORAGE TANK PROGRAM W o <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Y y* <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �9tp JtP <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PRM LOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ B TEMPORARY SITE CLOSURE •O <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY//&TE NAME CARE OF ADDRESS INFORMATION <br /> walk <br /> ADDRESS NEAREST CROSS STREETORPIDRATICN <br /> 1:1PARTNERSHIP ❑ STATE-AGENCY <br /> LOCAL-AGENCY 11FEDERAL-AGENCY <br /> OUAL ❑ <br /> COUNTYAGENCY <br /> CITY NAME r� STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> TYPE OF BUSINESS: 2 DISTRIBU 4 P LESSOR ✓Box,f INDIAN EPA ID a <br /> R <br /> RESERVATION or #of TANK`s <br /> 1 GAS STATION 3 FARM k5"OTHER TRUST LANDS ElAT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE I NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME: CARE OF ADDRESS INFORMATION <br /> 10 � t <br /> MAILING or STREET ADDRE ✓ x to indicale 13 PARTNERSHIP ❑ STATE-AGENCY <br /> aV 7 �/ /I jy ✓lA El El <br /> ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> V !�! ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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 Cl STATE-AGENCY <br /> ❑ CORPORATON ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ 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: I. H. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> FPERMIT <br /> TY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> � 6 37 (j l <br /> CAL AGENCY FACILITY ID k APPROVED BY NAME PHONE k WITH AREA CODE <br /> BER PERMIT APPROVAL DATE PERMITEXPIRATION DATE <br /> ODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED,/�YES NO ® 1!/PERMIT AMOUNT SURCHARGE AMOUNT7�ODE RECEIPT k BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST;+I OR MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 Y. <br /> FORM A(3-2-88) i <br /> DATA PROCESSING COPY <br />