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ural):T�rrc•o.--.._,.-......-.....v-.r,-wW-,.s.,�-�.s�-w..*..--- <br /> STATE OF CALIFORA WATER RESOURCES CONTRBOARD of <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION s° <br /> ., <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE r�-� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION yl 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE (01 6 <br /> CS <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 10101 <br /> FACILITY/SIT NAMECARE OFADDRESS INFORMATION <br /> A S <br /> ADDRESS NEAREST CROSS STREET ✓Smlo ineicale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> . + /� ,.( <br /> 11 CORPORATION ❑ LOCAL AGENCY ❑ FEDERALAGENCY <br /> LoI �SGa lOh ACli ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> tz�CI4 L_ r ( CA <br /> TYPE OF BUSINESS ❑ p TRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ ICAs STATION 3FAAM ❑ 5OTHEA TRUST LANDSESERVATION ❑ ATTHIS SITE I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 04 <br /> NIGHTS'. NAME(LAST FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE H WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <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 1/60.tolndicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <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 NOTIFICATION AND BILLING: I. ❑ U. ❑ it. ❑ <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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID It APPROVED BY NAME PHONE#WITH AREA CODE <br /> a ' <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> OCATION CENSUS TRACT Or SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE <br /> 3, Z 3 YES ❑ NO ❑ 10141169 <br /> PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> Waaa <br /> THIS FORM MUST BE ACCO ANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL� <br /> FORM A(3-2 <br /> DATA PROCESSING COPY <br />