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STATE OF CALIFORNIOR WATER RESOURCES CONTROCBOARD �a <br /> r�F <br /> W <br /> FORM 'A'. <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMAkILUlLlLLQSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) w <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> h� ult: - <br /> ADDRESS NEAREST CROSS STREET ,�✓Bovto Mi to 11PAATNEPSIIP ClSTATE-AGENCY <br /> LJ CyPPOPATION 11LOCAL-AGENCY ❑ FEGEML-AGENCY <br /> -70 / l� Lt(L u"?QlAL ❑ CGUNIYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> CG O CA S 1� L_ <br /> TYPE OF BUSINESS: ❑ p RIB Ofl ❑ 4 PROCESSOR ✓Bo%if INDIAN EPA ID a <br /> RESERVATION orN of TANK's <br /> ❑ 1 GAS STATION Ljjr3 FARM E] 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE ft WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> s s} y <br /> NIGHTS'. NAME(LAST,FIRST) PHONE N 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 /> S /,q- ;r- <br /> MAILING ar STREET ADDRESS ✓Box to ale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S Z <br /> MAILING or STREET ADDRESS ✓Bo oin0icale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ RPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 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. ❑ 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 K JURISDICTION K AGENCY R FACILITY ID# It of TANKS at SITE <br /> 3H = � l9 00u <br /> CURRENT LOCAL AGENCY F/ACILITYQMLPERMIT <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> L <br /> NUMERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> ON CSUPERVISOR-DI TRICT CODE BUSINESS,SNFILED NO ❑ DATE FILED/M SURCHARGE AMOUNT FEE CODE RECEIPT# f/BY: <br /> e <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(3-2-813) <br /> DATA PROCESSING COPY �� <br />