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STATE OF CALIFORNr WATER RESOURCES CONTROL BOARD Viz" ""' <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �a Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �: ;o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �""�""�� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ITE 1� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) CD <br /> N <br /> FACILITYISITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓BaFm Heinle ❑ PARTNERSHIP ❑ STATEAGENCY <br /> /q [I CORPORATION ❑ LOCALAGENCYEIFEDERAL AGENCY <br /> •/ / Geals� v'e, ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE K,WITH AREA CODE <br /> ec-ce cA 3� <br /> TYPE OF BUSINESS ❑ p RIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N M of TANK's <br /> ❑ 1 GAS STATION FARM ❑ 5OTHER TRUSTTYLANDS ATION of ❑ ATTHISSITOI!�) / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE IT WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST FIRST) PHONE#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 to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> q ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> y� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> Cl tt NAM STATE ZIP CODE PHONE N.WITH AREA CODE <br /> WAtn� <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING.,STREET ADDRESS ✓Box tointlicale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. ❑ 11. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION R AGENCY R FACILITY ID N M of TANKS at SITE <br /> U � 10Dv I l <br /> CURRENT�AL�.+EZY III I �D/1 APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER (E//ll/�Yl' L# SUPERVISOR-DISTRICT <br /> / AL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS CODE BUSINESS PLAN FILED !DATELFIIYES ❑ NO <br /> CHECK N PERMIT ACHARGE AMOUNT FEE CODE RECEIPT A <br /> 1 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 /> 1 FOr M A(3-2-BB) <br /> V DATA PROCESSING COPY <br />