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STATE OF CALIFORNIA WATER RESOURCES CONTR6L BOARD <br /> FORM 'A'- UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or/PERMIT APPLICATION : o <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE -4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) � <br /> FACILITY/ ENAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓8%oikd, ❑ PARTNERSHIP 0 STATEAGENCY <br /> 51 O ❑ EOEu Accu <br /> �xrv�Ex <br /> CITY NAME/t/ STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> ?FCA- CA 9 <br /> TYPE OF BUSINESS: ❑ ISTRIBUTOR ❑4PROCESSOR ✓Box it INDIAN EPA IDN ATIONiMTANK'# <br /> ❑ 1 GAS STATION SFA ❑5 OTHEfl 7RUSTYLANOS or ❑ 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#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME ,^ixn CARE OF ADDRESS INFORMATION <br /> MAILING or STREETA RES$ ✓Box to iMkate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> /T I JC7AbIBIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE DECODE PHONE 11,WITH AREA CODE <br /> A711 � 533 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE TONE#,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. ❑ it. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID N If of TANKS at SITE <br /> TUU / <br /> CURRENT LOCAL ARE NCJ(F ILITYI j APPROVED BY NAME PHONE#WITH AREA CODE <br /> IM •(/J� �i, <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOG 1CODE CENSUS TRACT1A SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATBF(/(�^ILED <br /> �J-�3 Sri Y� YES [:] NO E-1 � <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A t3-2-88) <br /> '%w DATA PROCESSING COPY .a/ <br />