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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND�STORAGE TANK PROGRAM <br /> SST FACILITY/SITE, INFORMnd/or PERMIT APPLICATION <br /> G, COMPLETE THIR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 2115F CHANGE OF INFORMATION ❑ 7 TLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE •Q <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILI /SITE NAME CARE OF ADDRESS INFORMATION <br /> I <br /> ADDRE NEAREST CROSS STREET ✓Box b wxare ❑ PARTNERSHIP ❑ STATE AGENCY <br /> CORP TION ❑ LGGALAGENCY ❑ FEDERAL AGENCY <br /> CITY NAME '�I/jpppp 101INGRIDUAL Cl WUNTYRGENCY <br /> / STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 <br /> _>PESSOR ✓Box if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑3 FARM OTHER RESERVATION or ❑ - #of TANK's Q <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT RSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORM A ION &ADDRESS - (MUST BE COMPLETED). <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indlo.te ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> El INDIVIDUAL 13COUNTY-AGENCYCITU NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRE - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to intlicale ❑ PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> El INDIVIDUAL FICOUNTY-AGENCYCITY NAME STATE 21P CODE PHONE k,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR OTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,A 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 K AGENCY k FACILITY ID If F#WITH <br /> at SITE <br /> lv (v 40 <br /> CURRE LOCAL AGENCY F ILI IDN APPROVED BY NAME REA CODE <br /> PERMIT NUMVER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAT N DE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILED <br /> 31 �� YES ❑ NO ❑ rof <br /> CMECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTk <br /> 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(3-2088) \ ' <br /> 1� � DATA PROCESSING COPY _\/\ <br />