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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD e <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Ej�r5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE / —4 <br /> 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> CA <br /> FACILII Y/SITt:NAMECARE OF ADDRESS INFORMATION <br /> Ul <br /> ADDRESS NEAREST CROSS STREET ✓Rm AOI ❑ PAIRNBSHIP ❑ STATE AGENCY <br /> ❑�,0fK6EATON ❑ UKAL-AGENCY ❑ FEDERALAGENCY <br /> IB'I0111DUAL ❑ C(UNlYAGENCI <br /> CITY NAME STATE ZIP CODE SITE PHONE ft.WITH AREA CODE <br /> �iSGL D� CA <br /> TYPE OF BUSINESS ❑ p D TRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID a <br /> ❑ 1 GASSTATION [pr3' ❑ 5OTHER TRUSTVATION LANDSO ❑ ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> NIGHTS: NAME(LRST.FIRST) PHONE 4 WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box lo,I,dw.le ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 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,ftcate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION O LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE ft,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. ❑ II. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION M AGENCYIN FACILITY ID N k of TANKS at SITE <br /> = = = 1 1 141 ol 1P-1 FTTT�l <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> SET � <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENS�TRACTT SUPERVIS�STRICT CODE BUSINESSPUN FILED NO ❑ DATFFIUEO <br /> CH CK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M l/L/�, BY^/�' <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) ft <br /> DATA PROCESSING COPY <br />