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STATE OF CALIFORA WATER RESOURCES CONTROBOARD /l'°'^' F' <br /> ZEn� o TM1\ <br /> t: <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> e COMPLETE THIS FORM FOR EACH FACILITY/SITE `9r��oa.`" <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION 7 PERM TLY CLOSED SITE Q <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 NAMECARE OF ADDRESS INFORMATION W <br /> C <br /> ADDRESS /�/I✓ NEA STCROSBSTREET ✓30,M UM 13 PARTNERSHIP 11 STATE AGENCY W <br /> ❑ CORPORATION 11LOCALAGENCY 1:1FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCT <br /> CITY NAME STATE ZIP CODESI E PHONE#,WITH AREA CODE <br /> '34-4 �i/l CA f �o)oc! jo�o`5 <br /> TYPE OF BUSINESS p DISTRIBUTOR ❑ 4 Pfl0 MR ✓Box if INDIAN EPA ID a /q�/`y_L /A� <br /> ❑ I of TANK' <br /> f GAS STATION ❑ 3 FARM OTHEA <br /> TRURESSTVLANDS ATION� ❑ /`/" AT THIS SITE Q <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If 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 /> II. PROPERTY OWNER INFORMATIO &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Dox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE K,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUXT BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ I VIDUAL ❑ COUNTYAGENCY <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 BILLING: 1. ❑ 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# JURISDICTION Al AGENCY# FACILITY ID# #of TANKS at SITE <br /> Mao I / Ffam 10 010 a <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT alt PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTSUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT/E�FI D <br /> ol 3j YES NO 1v <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(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.. --� <br /> FORMA(3-2-81 <br /> V DATA PROCESSING COPY <br />