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STATE OF CALIFORN19 WATER RESOURCES CONTROBOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION IZ o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE FJ`- <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a) <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) A <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Lame I <br /> ADDRESS NEAREST CROSS STREET ✓80,la Note ❑ PARTNERSHIP ❑ VATEAGENCY <br /> 99MLnwi;�r?, M ,r-/N ❑ CORPOM71ON 13LOCAL AGENCY ElFEDERAL-AGENCY <br /> V ❑ INDIVIDUAL ❑ COUNTRAGENU <br /> CITY NAME STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: F-]2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p <br /> RESERIf of TANK's <br /> F-11 GAS STATION F-13 FARM ❑ 5 OTHER TRUSTTVLANDS ATION DI ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to irtlicaie ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate Cl PARTNERSHIP Cl STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE k,WITH gflEA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# II JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN APPA VED BYNAME PHONE k WITH AREA CODE <br /> L <br /> PERMIT NUMBER PERMIT APPROVAL DATE MIT EXPIRATION DATE <br /> LCHECKK'# <br /> DE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILED <br /> © YES ❑ NO I <br /> PERYIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN B <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 /> ORM A(3-2-88) • <br /> DATA PROCESSING COPY <br />