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5E"y'f;._v <br /> STATE OF CALIFORN� WATER RESOURCES CONTRO B �.OARD . � '""^ sA <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM � o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �,,! COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY }+Sl NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) I <br /> FACILITY/SITE NAME r CARE OF ADDRESS INFORMATION <br /> LLE 6. P P N <br /> ADDRESS NEA EST CROSS STREET ✓ tatd <br /> BwI 0 PARTNERSHIP 0 STATE <br /> E-AGENCY <br /> N1 0 OORPORATION 0 LOCAL-AGENC! 0 EEDERA4AGENCI W <br /> ' OLILUr G N 0 INDIVIDUAL 13 COUNTY-AGENL <br /> CITY NAME STATE CODEITE PHOVE 1,WITH AREA CODE ItJ <br /> CA 15205 209 �5 5 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4PROCESSOR I ✓Box it INDIAN EPA ID#ESE #oI TANK'# <br /> ❑ 1 GASSTATION ❑3FARM CW5 OTHER TRUSTYLANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> D YS: Nr (LAST,FIRST) PHONE WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> E.DW <br /> A_Pb <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 n CARE OFADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE HONE It,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 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. 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 /> COUNTYIN JURISDICTION# AGENCY# #of TANKS at SITE <br /> EE = = a 13 X, <br /> CURRW LOCAL AGENCY FACILITY ID# P VED BY NAM PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE )fERMft EKPIRATI NDATE <br /> I <br /> OCATION CODE CENSUS g5# SUPERVI OR-DIS RIOT CODE BUSINESS PLAN FILED DATE FI ED <br /> ?'3 YES ❑ NO <br /> HII # PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If 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(3-2-88) <br /> DATA PROCESSING COPY S <br />