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STATE OF CALIFOR A WATER RESOURCES CONTROL BOARD <br /> �as` <br /> FORM `A': � �o <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITFACILITY/SITE, INFORMATION and/or PERMIT APPLICATI <br /> OP P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> E16, <br /> K ONLY 1 NEW PERMIT ❑ 3 RENEW AL PERMIT ❑ 5 CHANGE OF INFORMATION <br /> PE NTLY CLOSED SITE <br /> ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N <br /> FACI TEN ME CARE OF ADDRESS INFORMATION <br /> ADORES NEAREST CROSS STREET ✓Bax to lndiwle Cl PARTNERSHIP ❑ STATE AGENCY <br /> E7 <br /> ' S ❑ CORPORATION ❑ COUNTY <br /> ❑ FEDERAL hGENC'! <br /> f!.� S ❑ INGNIpUAI Cl WUNttAGENCY <br /> CITY NAM ,./ STATE ZIP C OE SITE PHONE p,WITH AREA CODE <br /> �OL4 ! CA � � O <br /> TYPE OF BUSwESs 2 DISTRIBUTOR 4 PROCESSOR ✓Box ii INDIAN ❑ EPA ID # #of TANK's <br /> ❑ ❑ RESERVATION or AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE N WITH AREA CODE <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) <br /> NIGHTS. NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME, <br /> vC <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PH NE k,WITH AREA fCODE <br /> CITY NAME <br /> � <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESSµ^ �— ✓Box to indicate [J PARTNERSHIP [ISTATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> STATE ZIP CODE PHONE k,WITH AREA CODE <br /> CITY NAME <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. El it. F1 III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> TI I �T'I ILII FACILITY --- #of TANKS at SITE <br /> COUNTY# JURISDICTION# AGED—J <br /> CURRE AL ADENY FAC ITY IDAt�� <br /> APPROVED BY N _ E M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> __ DATE FILED <br /> LOCATI SUBTRACTM SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> 3 ry0 � YES � NO <br /> DD <br /> CHECK PERMIT AMOUNT-' SURCHARGE AMOUNT FEE CODE RECEIPT# By- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />