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qfP eVMeTi*N <br /> STATE OF CALIFORNI10 WATER RESOURCES CONTROL. BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> -o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONo P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ ) NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE Q) <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BEoCOMARE OF PLETEDDRESS ) <br /> MAnoN <br /> FACILITY/SITE NAME <br /> j ,'o , <br /> NEAREST CROSS STREET ✓COIFORATJO 0 LOCALpARTNAGEN Cl STATFAGENCY <br /> L-AG <br /> 1 ❑ fAAPGAATIDN ❑ LOCAL ❑ FEDERAL-AGM <br /> ADDRESS I c) u INDIVIDUAL 0 COUNTY-AGENCY <br /> L I ZIP CApE� /, SITE PHONE a,WITH AREA CODE <br /> STATE I 7 V <br /> CITY NAME ' CA <br /> Epp ID a XoI TANK's <br /> TYPE OF BUSINESS: ❑3 DISTRIBUTOR 4 PROCESSOR V Box if INDIAN RESERVATION or ❑ AT THIS SITE �— <br /> ❑ i GASSTATION ❑3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> AflEA CODE <br /> DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE p WITH <br /> AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE C01 ADoOMPLLETEoD) <br /> NAME <br /> C> VY) <br /> ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> MAILING or STREET ADDRESS 0 CORPORATION 0 LOCAL-AGENCY [IFEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#.WITH AREA CODE <br /> CIN NAME <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> OMPLETEDMATION <br /> EAM <br /> Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> or STREET ADDRESS 0 CORPORATION 0 LOCAL-AGENCY CFEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCYHONE A.WITH AREA CODE <br /> STATE ZIP CODE <br /> ME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WH)CH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ E ❑ 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&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> � <br /> FACILITY ID# #of TANKS at SITE <br /> COUNTY# JURISDICTION AGE <br /> mAPPROVED BY NAME PHONE X WITN AREA CODE <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> N FILED <br /> DATE FILED <br /> SUPERVISOR-DISTRICT CODE BUSINESS PLA <br /> LOCATION CODE CENSUSTRACT YES NO <br /> SURCHARGE AMOUNT FEE CODE <br /> RECEIPT If BY: <br /> CHECK X PERMIT AMOUNT <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASTf R MORE TANK PERMIT FORM `B' APPLICATIONIS), UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-fie) FILE COPY • <br />