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/SE.......iirti tie• <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD . <br /> FORM `A': =4 bm <br /> UNDERGROUND STORAGE TANK PROGRAM -o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE y <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE z <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) W <br /> CG <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS BEST CROSS STREET [I CORPORATION ❑ LARTNE�HIP El STATE AGFNC� <br /> OCAL AGENT ❑ FECML AG NCY W <br /> (lV�f{J_f\ ❑ INDIVIDUAL ❑ CWNIY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> L-49 b CA 52' <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # If <br /> of TANK'S <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GASSTATION ❑ 3 FARM 5 OTHER TRUST LANDS <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 /> NIGHTS: NAME(LAST,FI ST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#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 D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> U"( 1-1INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATf ZIP CODE PHONE#.WITH AREA CODE <br /> CTOS I-1 OIC I Or 40mv <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> j` ARTHAS NTAGNErz- <br /> MAILING or STREET ADDRESS ✓Box to indicate I] PARTNERSHIP D STATE AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ` ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE <br /> Ui VILLC K /4 Q-2-11 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(t)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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# JURISDICTION# AGENCY# LITY ID# — #of TANKS et SITE <br /> aLl' s <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NA PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> PERMITHUMBER <br /> LOCATI N CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PSND N FILED DATE F� ., <br /> ciol •�� 3 ❑ ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: J <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) <br /> '���'U DATA PROCESSING COPY <br />