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l—o <br /> .iTATE OF CALIFORN WATER RESOURCES CONTROBOARD <br /> 4�. <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM = " �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : 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 F—a <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ' <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) v <br /> CI'I <br /> FACILI SITE NAME ^_ � CARE OF ADDRESS INFORMATION <br /> V C/v 1 <br /> ADDRESS NEAREST�D� EET ✓kOtl Ydi ❑ PARTNERGHF ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCALAGEIICf ❑ FEDERALAGENCY <br /> P M �/a Fly ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NA STATE ZIP CODE S PHON N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑4 PR_QGMR ✓Box if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER RESERVATION or ❑ of TANK's <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> NI HTS: NAME(LAST,FIRST) P ONE X WITH AREA CODE NIGHTS: -RAOIETLAST,FIRST) PHONE N WITH AREA CODE <br /> 11 PHTS 4at�T) <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME _ CARE OF ADDRESS INFORMATION <br /> �G�IU/ti V W, /-, <br /> N60H L <br /> MAILING (STREET ADDRESS %1 Box to indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> // �/ O C PORATION 11 LOCAL-AGENCY 11FEDERAL-AGENCY <br /> /oar- a DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE X.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 ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X,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. ❑ If. EvrIII. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE,IS TRUE AND CORRECT— <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID-#_" _ #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY # APPROVED BY N PHONE X WITH AREA CODE <br /> � 3v <br /> P&ANIT NUMB R - PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION COOE CENSUS TRACT# SUPERVI R- (STRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23 YES NO �[ 3 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY.. <br /> 41 <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 /> FORMA(3-2788) 0. <br /> DATA PROCESSING COPY <br />