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1118 j,P.17T11,1VT. <br /> STATE OF CALIFOR <br /> WATER RESOURCES CONTROL BOARD <br /> FORM 'A': " - <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH AGILITY/SITE `�<„oaH�� 10 <br /> MARK <br /> ONE ONLY <br /> ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EEIS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE )_h <br /> ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) Imo► <br /> FACILITY/SIT/�/J <br /> E/7PJAE CARE OF ADDRESS INFORMATION W <br /> 7 <br /> ADDRESS <br /> CY <br /> Axe- NEAREST CROSS STREET ✓Dox lYm.le ARTNERS6IP ❑ STATE AlrN <br /> ❑ CORPORATION ❑ LOCALAGENCI ❑ FEDERAL AGENCY INDIVIDUAL ❑ COUNTY CITY NAME STATE Z CODE <br /> �! SITE PHONE k,WITH AREA CODE <br /> TYPE OF BUSINESS //lam ID <br /> ❑ 2 TRIBUTOR CA <br /> ❑5 PROCESSOR ✓Baz if INDIAN EPA ID a <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUSRESERESETVATION LANDS 0 ❑ A. TANK's o� <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE ft WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> filo CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz t.,,,c,.T, ❑ PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CI TY NAME <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE p,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS '/80.m,,,d,. N ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> El INDIVIDUAL CICOUNTY-AGENCYCITU NAME STATE ZIP CODE PHONE N,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: 1. II. ❑ 111.❑ <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 P JURISDICTION R AGENCY A FACILITY ID R K of TANKS at SITE <br /> M <br /> CURRENT LOCAL AGENCY FACIIL,II ID IT APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER C!/17 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAT N CODE CENSUS TRACCTTI2 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATEPOLED <br /> YES NO — <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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 /> I FORM A(3-2-68) <br /> 'W// DATA PROCESSING COPY <br />